Michael Palmer: Flashback

"Amen, " shouted the twins. "Amen."

The three of them, father and sons, sat alone at the table. Outside, the storm clouds had arrived, bringing with them a premature dusk. The women were in the kitchen, Annie in the breakfast nook, Cinnie and Lisette by the sink, loading the dishwasher for the second time, chatting about the upcoming Women's Club bake sale, and keeping watch on the twins, who had taken Cheap dog out back to play in the meadow. In a manner quite consistent with his belief that business matters and women should be separated whenever possible, the Judge had kept the conversation light until the last of them, Annie, had left the room. Then, after a few sips of coffee, he turned abruptly to Frank. "Guy Beaulieu came to see me yesterday, " he said. "So?"

"He says Ultramed and that new surgeon, Mainwaring, have just about put him out of business at the hospital."

"Jason Mainwaring's not new, Judge, " Frank said patiently. "He's been here almost two years. And no one-not him, not Ultramed, not me, not anyone-is trying to put Beaulieu out of business. Except maybe Beaulieu himself. If he'd be a little more cooperative and a little more civil to people around the hospital, none of this would be happening."

"Guy's a crusty old devil, " the Judge said, "I'll grant you that.

But he's also been around this town nearly as long as I have, and he's helped a lot of folks."

"What's all this about? " Zack asked. The Judge was hardly a spontaneous man, and Zack could not help but wonder if there was a reason he had postponed this conversation through four hours of golf to have it now.

Frank and the Judge measured one another, silently debating whose version of the story Zack was to hear first. The contest lasted only a few seconds. "A short while back, " the Judge began, obviously unwilling openly to concede Frank's "almost two years,"

"Ultramed-Davis brought a new surgeon into town, this Jason Mainwaring."

"I met him, I think, " Zack said. He turned to Frank. "The tall, blond guy with the southern drawl? " Frank nodded. Zack remembered the man as somewhat distant, but polished, intense, and, during their brief contact, quite knowledgeable-more the type he would have expected to see as a university medical-center professor than as a mountain community-hospital general surgeon. "Well, " the Judge went on,

"apparently Guy was already beginning to have some trouble getting a lot of his patients admitted to the hospital."

Frank sighed audibly and bit at his lower lip, making it clear that only courtesy kept him from interrupting to contest the statement. "More and more, his patients-especially the poor French-Canadian ones-were being shipped to the county hospital in Clarion. Then rumors started floating around town about Guy's competence and all of a sudden, all the surgical cases who could pay-those with insurance, or on Medicaid-were going to this Mainwaring. I've heard some of the rumors myself and, let me tell you, they are vicious. Drinking, doing unnecessary internal exams on women, taking powerful drugs because of a small stroke…"

"Is there truth to any of them? " Zack asked. During the summer between his sophomore and junior years at Yale Med, he had worked as an extern at the then Davis Regional Hospital, and Beaulieu had gone out of his way to bring him into the operating room and to nurture his growing interest in surgery. It was a concern he had never forgotten. The Judge shook his head. "According to Guy, there have been no specific complaints from anyone. Just rumors. He says that about eighty percent of his work now is charity stuff at Clarion County, and that he hasn't operated on a non-French-Canadian patient at Ultramed for almost a year.

He says the whole thing is a conspiracy to get back at him because he was so opposed to the sale of the hospital to Ultramed in the first place."

"That's ridiculous, " Frank said. "Mainwaring's getting the cases because he's good and he works like hell. It's as simple as that. You know, Judge, I don't think it's fair for you to take Beaulieu's side in this thing."

Clayton Iverson slammed his hand down on the table. "Don't you ever dare tell me what's fair, young man! " he snapped. "The provisional phase in our contract with Ultramed still has a month to run. I convinced the board of trustees to sell out to them in the first place, and by God, the three weeks until our meeting and vote is more than enough time for me to convince them to exercise our option and buy the damn place back."

He breathe deeply and calmed himself. Zack glanced over at Frank. Though he was staring at their father impassively, his hands were clenched and his knuckles were bone-white. "And let me make this clear, " the Judge went on, "I haven't taken anyone's side. As a matter of fact, Frank, I resented his implications that you were in any way involved with his problems, and I told him so. He apologized and backed off some, but he's hurt, and he's angry.

I promised him I'd speak to you-both of you-about it… ask you to keep your eyes and ears open. I feel we owe it to him. You were too young to remember, Frank, but that man all but saved your life when your appendix burst."

Frank's fists relaxed a bit, though Zack could tell that he was still smarting from the Judge's threat. Personality clashes, power plays, and political machinations were, he knew all too well, as omnipresent and as integral a part of hospital life as IVS and bedpans. But he sensed something more to all of this-something virulent. "Annie!"

Cinnie Iverson's cry was followed instantly by the crash of dishes. With reflexes born of years of crisis, Zack was on his feet and headed toward the kitchen as Frank and the Judge were just beginning to react. Annie Doucette was on the floor. Her back and neck were arched, and her limbs were flailing uncontrollably in a grand mal seizure. As Zack knelt beside the woman, he felt the change sweep over him.

Early on, he had heard about the phenomenon from other, older docs, but did not undergo it himself until midway through his second year of residency, when he witnessed the cardiac arrest of a patient. In that moment, his world suddenly began to move in slow motion. His voice lowered and his words became more measured, he sensed his pulse rate drop and all his senses heighten. It was unlike anything he had ever experienced in similar emergencies. Movements became automatic, observations and orders instinctive. Dozens of facts and variables were processed instantly and simultaneously. Later, with the patient successfully resuscitated and stabilized, he would learn from the nurses that he had acted quickly, decisively, and calmly. It was only after hearing their account of his performance that he realized fully what he had done. The change had been part of him ever since. "Mom, call an ambulance, please, " he said as he rolled Annie to one side to prevent her from aspirating her own stomach contents, should she vomit. His fingertips were already at the side of her neck, feeling for a carotid pulse. As the change intensified, all sense of the woman as a friend, a loved one, a patient, yielded to the objectivity of assessment. If it became necessary, in any way, to hurt in order to heal, then hurt he would. "Frank, my medical bag is in a large carton at the back of the van. Could you get it, please? " Please. Thank you. The use of these words during a crisis kept everybody calmer, including, he suspected, himself. Stroke, heart attack with arrhythmia, epilepsy, sudden internal hemorrhage causing shock, hypoglycemia, simple faint mimicking a grand mal seizure, the most likely diagnostic possibilities flowed through his mind, each accompanied by an algorithm of required observations and reactions. Annie's color was beginning to mottle. Her back remained arched and her arms and legs continued to spasm. Her jaw was clenched far too tightly to slip any buffer between her teeth. Again and again, Zack's fingertips probed up and down along the side of her windpipe, searching for a pulse. She had had chest pain at the table. Zack felt certain of that now. Heart attack with an irregular, ineffective beat or complete cardiac standstill moved ahead of all other possibilities in his mind. "Judge, are you okay to come down here and help? Good. I'm going to put her over on her back. If she starts to vomit, please flip her back on her side, regardless of what I'm doing. Lisette, check the time, please, and keep an eye on it."