Code Blues Page 7

  Mireille smiled. "We all know he'd never go anywhere without his pager. It was like his lover. The killer took it away after murdering him." She grabbed my arm, her fingers sinking painfully into my flesh. "What about his cell phone? He always carried it too, so he could call back right away."

  I tried to ease my arm out of her grip. "I didn't see any cell phone. Just his glucometer and his wallet."

  "Yes!" Spit flew out of her mouth and landed on my cheek. I jerked back. She laughed, said sorry, and handed me a napkin from the pile on the coffee table.

  At least she'd stopped gripping my arm.

  As I wiped my face, I had to add, "But if he was hypoglycemic, he might've—"

  Tucker was nodding thoughtfully, but Mireille's hand shot out as if to snap my words out of the air. "Non! I am telling you, I knew him better than anyone in this room, and he never left home without his pager clipped to his belt and his cell phone in his left pocket!"

  The ring of agony in her words silenced us.

  Tori laid her hand on Mireille's forearm. I could see Mireille's muscles clench in her arm and in her jaw, but she forced herself to take a deep breath. "Okay. Good. I wanted to talk about Kurt. We did. So thank you. Please, let's eat some more. There's plenty of food."

  I felt obliged to take a few more sips of water, and Tucker complimented Tori on her garlic bread, but we all started shuffling our feet and taking peeks at our watches.

  "Thanks for inviting us," Tori said.

  With a relieved sigh, we rose to our feet. Robin shoved Alex into recovery position and propped him up with cushions from the sofa, but Robin was the first to take off without bothering to air-kiss Mireille's cheeks. The last thing I saw, when I waved goodbye, was Mireille's green eyes staring at me from the doorway. She no longer pretended to smile.

  Chapter 7

  It was almost a relief to go to work the next day. I wasn't sure what to think anymore. I'd arranged Henry into so many positions, I'd finally left him sitting with his knobby hands together, roughly approximating prayer position. No more bad luck, please.

  In fact, I started off with a stroke of fortune. Dr. Dave Dupuis was on again for my evening shift, while Dr. Callendar was nowhere in sight. Dr. Dupuis looked calm and stork-like again, as he sat in a wheeled black chair at the nursing station, his feet propped on the base. "Hi there," he said. "You all right?"

  Close enough. "Yeah. You?"

  He nodded. "I've got a good chest pain in B. Go look at her."

  Right down to business. I liked that.

  In resus room B, I introduced myself to Mme. Cartier, an 82-year-old woman. Behind the white flannel blanket she clutched to her chest, her blue gown sagged so low on her chest that I could see her protruding ribs. Her hands were like the stereotypical witch's claws, the fingers bent and knuckles thickened by arthritis, the nails horn-like and filed to a point.

  She was a bit hard to understand, because she'd forgotten her dentures at home and tended to mumble, but I understood that she'd had a burning chest pain for the last two days, radiating to her neck and jaw. She hadn't come in until this afternoon. "I thought it was nothing."

  Her daughter, a brunette with careful makeup, picked up the story. "She thought it was her stomach. Toujours mal au coeur, eh, maman?" She turned back to me. "She doesn't want to come to the hospital all the time."

  "So what was different this time?"

  The daughter screwed up her face in thought. "More—intense, eh, maman? She called me, but by the time I convinced her to come—" She shrugged as if to say, What can I do?

  I wasn't getting much of a story out of the two of them, so I picked up the EKG. My eyes popped. Big ST elevation from V1 to V4.

  "What do you see?" Dr. Dupuis came up behind me.

  I pointed it out, and whispered, mindful of the patient, "Big anterior." A big heart attack. A bad one.

  "Uh huh. And did you listen to her chest? And see her chest X-ray?"

  I had jumped right from history to the EKG, so I backtracked to the physical exam. I listened to her heart and chest and checked her abdomen. The most remarkable finding was poor air entry and crackles at both lung bases.

  I walked out of resus to the hallway between the ambulatory and acute (stretcher) sides, where the light boxes were posted. Mrs. Cartier's X-ray was already up. Instead of nice, black, air-filled lungs, they were quite white from fluid both in and around the small air sacs called alveoli. Congestive heart failure. When the heart doesn't beat hard enough, as in Mrs. Cartier's case, because she had had a heart attack, the fluid backs up into the lungs.

  I found Dr. Dupuis in the nursing station, sitting by the monitors. I said, "We have to thrombolyze her."

  He tipped his head back to look at me. "Do we? What are the criteria?"

  "Well, she has a big ST elevation in four contiguous leads, and she's had chest pain for more than six hours—"

  He smiled. "Yes, but she's been having pain for how long?"

  I pressed my lips together. Damn. "Two days."

  "And how old is she?"

  I sighed. "Eighty-two." After more than twelve hours of chest pain, and over age seventy-five, the benefits of thrombolysis—lysing the clot, reducing death and recurrent heart attacks—drops significantly. By now, the risks outweighed the benefit. I could cause this lady's brain to bleed, instead of solving her heart attack.

  Dr. Dupuis watched me work it out. Then he said, "You could make an argument for thrombolyzing her, because it's a big anterior. But I'd rather do rescue angioplasty. She's supposed to go over to the Jewish, whenever they can take her. She's hemodynamically stable, but we have to watch her. Read up on thrombolysis and PCI."

  "Okay." Pretty cool case. Then I went to see a 90-year-old man. According to his son, the patient had fainted and hit his head on the sink. I was spotting a trend in St. Joe's emerg patients: old and frail. Well, except for Dr. Kurt yesterday, and he'd been beyond our help.

  I shook my head steered my mind back to the case at hand. I smiled at the patient. He'd put the hospital gown on over his ribbed white undershirt and tighty-whities. "Had you just urinated or had a bowel movement, sir?"

  He looked puzzled, twisting to check with his son. "No."

  I wasn't a pervert. Voiding and defecation stimulate the vagal nerve, which could make a patient faint. But otherwise, I was running out of questions to ask. I needed to read up on syncope, too. I fumbled around some more, and when I couldn't think of anything else, I did a physical exam. The guy had a goose egg on his forehead. His right eye was starting to swell shut. No lacerations to sew, though. The rest of his exam was pretty normal.

  When I reviewed this case with Dr. Dupuis, a nurse interrupted. "Dave, can 11 go?"

  They debated discharging bed number 11 while I wanted to call him Dave, too. Like I said, at Western, it wasn't uncommon for residents to called staff physicians by their first names. I wanted that promotion. He probably wouldn't mind. Still, I decided to defer that until I got to know him better. After he finished with the nurse, I said, "So, it's a 90-year-old man with syncope."

  Dr. Dupuis replied, "So what do you think?"

  Did he not hear my history and physical? I stared at him blankly. "Well, it's syncope."

  "But what do you think caused it? How do you want to investigate it?"

  He expected me to manage this patient as if I were a real doctor. Man. Here was my real promotion. As a med student, getting the H&P was my main job and managing the case was a bonus, but not expected, unless I was running the floors at night on surgery or medicine. As a resident, I had to pull my weight during the days, too. I started going through the algorithm I'd been taught. Was this neurogenic, meaning brain-based, like a seizure? Cardiac, meaning heart-based, like a heart attack or arrhythmia? Or the combination of neurocardiogenic, like blood pooling in the legs? Dr. Dupuis listened patiently, even as nurses interrupted him: "Dave, bed 14 won't stay in the room. I want sedation." "Dave, number five is still in pain." "Dave, does two still need the
monitor? I've got a chest pain in triage."

  Somehow, he was able to sort through these and still keep a mind on my story. He asked, "Do you think this guy had a seizure?"

  "No. I mean, I could ask again, but he didn't have any seizure-like activity, and he didn't bite his tongue and he wasn't incontinent. He said he was oriented when he came to."

  "So what are we left with?"

  "Cardiac."

  "Anything else?"

  "Well." I had to think. "It could be that his electrolytes are off, or that he's orthostatic."

  Slowly, our plan came together. Basic blood work, in case it was anything that could be picked up simply. Serial troponins, EKG, and cardiac monitoring for the heart component. He'd still need a Holter monitor as an outpatient.

  "Good," said Dr. Dupuis. "Do posturals, and do a rectal exam next time. Make sure he's not bleeding out the back end." But he didn't seem mad, or contemptuous, or superior. More matter-of-fact than anything else. How I imagined Dr. Radshaw would be.

  I returned to the bedside to take the posturals, the blood pressure and heart rate lying and standing. The patient hated standing there in his shorts and hospital gown with his skinny white legs sticking out, and I found it awkward to balance the cuff and pump it up while he was standing. But we got through it. There was no significant difference in readings.

  Next, the rectal exam. Some people don't mind doing it, but I dread the entire ritual, even just getting them to pull down their shorts and roll over on their sides, with their hairy bums sticking out. The patients hate it, too.

  When I did my first few rectals, I worried that I wouldn't be able to find the patient's anus, a secret fear I confessed to no one. Luckily, I always did find it. But sometimes I had to nudge around with a lubricated finger before I managed to squirm it in. This was one of those times.

  "You're hurting meeeee—" squeezed out the patient.

  "You're hurting him!" accused the son.

  I hurt him even more when I dug around a bit, to make sure I got stool and didn't have to go in a second time. "I'm sorry." I checked the gloved finger. Yep, stool. Mission accomplished. "All done, sir," I chirped, and ran off to smear the sample on a little yellow cardboard card that looked kind of like a matchbox. I flipped open one side, revealing two windows for me to smear with stool. Then I closed that side and flipped open the other, to squirt a few drops of developer. A positive sample turned dark blue-green. Negative was no color change. Like right now. No blue-green, just the paper turned translucent, so that I could see the poo on the other side.

  I washed my hands thoroughly, documented my negative findings, and picked up the next chart. It was an elderly lady with dizziness.

  "Dave, Bed B is desatting," said a nurse with big brown eyes.

  Dr. Dupuis and I took one look at each other and tore off to the resus room. Mrs. Cartier was sitting bolt upright in bed. A big oxygen mask covered her nose and mouth, but her eyes were wide open, and she was using the muscles in her neck to help her breathe. With every breath, a large, clear bag attached to her face mask inflated and deflated.

  Her sats were at 90, but only just. Even with a non-rebreather mask, she was hovering.

  I expected Dr. Dupuis to start barking orders. Instead, he turned to me and asked, "So what do you want to do?"

  I blinked fast. "Uh...give her Lasix." That would help her pee out the water in her lungs.

  "Okay. How much?"

  I was starting to sweat. "Forty?"

  He checked the chart. "She already got forty milligrams when she came in, from another resident."

  "Okay. Eighty."

  "Good. Anything else?"

  "Uh..."

  "How about this?" He tapped a bottle of nitroglycerine that was already hung up and attached to the IV in her arm.

  I smiled with relief. "Yeah. Turn it up."

  "Okay. The nurses can take care of that. They titrate to pain, resps, and systolic BP. Anything else?"

  I cast my eye around the resus room. The respiratory technician was coming through the ER doors, pushing a large, blocky machine on wheels. "CPAP?"

  "Yes! Continuous positive airway pressure, to splint the airways open. I knew you'd get it."

  I hadn't been so sure, but I smiled, relieved. Dr. Dupuis was on my side. He waited for me to come up with the answers, instead of running it. He was a good teacher.

  The RT, a balding guy in a lab coat, fitted a giant transparent mask over the woman's face and tightened the straps at the back of her head. It gave her an astronaut look. The woman in the bubble.

  "I can't breathe!" she said, muffled behind the mask.

  "Just wait, madame," the RT said, pressing some buttons on his machine. "When you get used to it, you'll feel much better." Mrs. Cartier nodded and he turned to Dr. Dupuis. "I heard about Kurt."

  "Yeah."

  "I never would have guessed he'd screw up his insulin."

  Dr. Dupuis indicated the patient with raised eyebrows.

  The RT nodded and lowered his voice. "Sorry."

  "Later," said Dr. Dupuis. "Come find me when she's stable. We'll talk." With that, he left the room.

  I followed. "So, uh, about Dr. Radshaw—"

  His shoulders tensed. For a second, his steps slowed. "Yeah."

  "Do you really think it was an accident?"

  He stopped just shy of the nursing station to face me. A muscle worked in his jaw. He lowered his voice. "That's for the police to decide."

  For the first time since I'd met him, his eyes didn't quite meet mine. Maybe he'd gotten the lecture from the police, too. "Yes, but I wondered what you thought?"

  "You know as much as I do."

  "Yes, but you knew him much better than I did," I said. "All I knew was that he had a moustache, he was a good doctor, and he answered all his pages."

  Dr. Dupuis's mouth twisted into a grin. "Actually, that's a pretty good summary if you add in that we'll all miss the hell out of him."

  He was talking to me again. I pressed my advantage. "So you agree about the pager, right? Don't you think it's strange he wasn't wearing it? Or his cell phone?"

  He sighed. "Yes, I do. But it's not proof of anything."

  "Dave!" called a nurse. "I need you to write a Gravol for twelve!"

  "Do it as a verbal," he called back. He glanced at the charts piling up against the far Plexiglas wall of the nursing station and started heading toward them. "Listen. Wait for the autopsy. That'll give us more information."

  That was true. They could approximate the time and cause of death and take blood and urine samples. Maybe I could even attend the autopsy. That would be cool, if unlikely in a coroner's case.

  Dr. Dupuis was already five steps away, his bony hand stretched out for the first chart. "Here, have an atypical chest pain."

  Even as I took the chart, I chewed over his words. Dr. Dupuis was one sharp clinician. I still got the feeling he wasn't telling me the whole story, but when it came right down to it, I knew he was right. We needed proof Dr. Radshaw had been murdered. The autopsy would probably provide it.

  But something in me wasn't content to sit around and wait for the report. The more I found out about Dr. Radshaw, the more I wanted to uncover the truth. I decided to talk to the person who probably knew him the best. His girlfriend.

  Chapter 8

  When I got home, I picked up my phone and checked the message. "Call me. No matter how late you get in."

  Alex.

  It was almost 1 a.m., but I didn't have to work the next day, so I changed into my raggedy, mauve, Brown University night shirt and called from my sleeping bag. He picked up on the first ring.

  I said, "So, you're alive?"

  He groaned. "Barely. Listen. I'm so sorry about Friday night. I want to make it up to you."

  "What happened?"

  He sighed. "Family emergency."

  I tried to gauge his tone. It was hard over the phone. I was still torn between anger and "seize the day, life is short" forgiveness. What kind o
f family emergency crops up at 10 p.m.? But, as a wannabe emerg doc, I knew that anything could crop up at any time. "Really?"

  "Yeah. Listen. Can I take you out to lunch tomorrow?"

  I sat up cross-legged, propping my back against the wall. A sleeping bag is not enough bum cushion against a hardwood floor. "Maybe."

  "If I grovel enough?"

  "Yeah."

  I heard a tap, like he'd put the receiver down on the floor, then some creaks, a lot of swishing, and a few groans. He picked up the phone again. "Was that good?"

  I had to smile. "I prefer live groveling."

  "Ah. That was a mere taste! If you let me take you out for lunch, I'll do real, live, up-close-and-personal groveling."

  "Hmm." He always made me laugh. On the other hand, desertion and drunkenness were two serious strikes. "Are you going to be sober?"

  He groaned. "Believe me, after last night, I'm going to be sober for the rest of my life."

  "I find that hard to believe."

  "Just find me an AA program, and I'm there!"

  There was a time, like a few months ago, when I would have written him off right after the café. Unreliable. Good-bye. But I'd been walking the straight and narrow my whole life, and where had it gotten me? A medical degree. One serious ex-boyfriend, and some forgettable dates. I was twenty-six years old and living alone in a new city. I wanted to take some chances. "Okay."

  "Okay, you found me an AA program?"

  I laughed. "No. Okay for lunch."

  "You're the best."

  I stretched out my legs. "Just don't forget that."

  ***

  At 10 a.m., I rode my bike up St. Joe's semicircular driveway and bumped on to the grass under the poplar trees. Early for lunch, but I wanted to ask Dr. Radshaw's girlfriend some questions.

  The receptionist told me that obstetrics was on the fourth floor. I walked through the main entrance, where St. Joe's had spent all its money on a face lift, what with the aquarium and all. As soon as I walked down the main ramp, it was all harsh fluorescent lights, fake tile floor, and yellowing paint.