Michael Palmer - Flashback

Frank was pacing, elenching and unclenching his fists and then rubbing his hands on the sides of his trousers. "For years now, ever since you fell on that ski slope and I got to go to Colorado, you've been waiting for the chance to get back, to ruin me. Sitting in the stands all those years cheering and clapping with the others, and all the while hating my guts because you couldn't stay on your skis-"

"Frank, that's crazy."

Revising upward his estimate of how much Frank had had to drink, Zack could only settle back in his chair and watch. "I told them things were going just fine up here, " Frank ranted on. "I told them we didn't need any goddamn neurosurgeon, least of all you. Well, let me tell you something, Zack-o. Tougher nuts than you have tried to fuck with me.

Where are they now?"

He whirled and leveled a finger at Zack's face. From the corner of his eye, Zack saw Cheap dog again stiffen. "Now just listen, and listen to me good, " Frank said. "Things are going to change around here or you're out. I've worked too hard to get this place the way I want it to have anyone screw it all up-especially someone with a twenty-year-old chip on his shoulder. So just back off. Let up on the staff, on the Judge, and on Lisette, or I swear, Zack-o, I'll come down on you like a ton of bricks."

Without waiting for a response, he spun on his heel and stormed from the house. Moments later, the Porsche screeched away. Zack sat in numb disbelief. A twenty-year-past skiing accident, an innocent, unfulfilled high school romance. Was Frank merely drunk and tired, or was he truly crazy?

Let up on the staff. The warning would have gone unheeded under any circumstances. But now, there was not even room for dialogue or tact, An eight-year-old boy was drifting toward insanity and possibly death, and, consciously or not, someone at Ultramed-Davis knew why. Zack glanced at his watch. It was after two. He picked up a book of crossword puzzles that were far enough beyond his ability to be soporific, and shuffled to the bedroom. What he needed now, more than anything else, was some sleep, because warning or no warning, Frank or no Frank, he was going to get some answers-beginning in less than seven hours with Jack Pearl.

The surgical residents at Boston Muni traditionally spoke of exhaustion in terms of the Wall-the moment when a physician ceased to function with any creative effectiveness. Throughout training, one was either approaching the Wall, up against it, or, when operating solely on the gritty-eyed fuel of caffeine and nervous energy, beyond it. At 6,45, when his clock radio switched in on the final two verses of an a cappella version of "Au Clair de la Fontaine, " Zack could distinctly remember seeing three, four, and five o'clock flash on its digital display. His bedside light was still on. The crossword puzzle book with, perhaps, a dozen or so items out of one hundred thirty filled in, rested in his chest. The pencil was still wedged between his fingers. Across the room, Cheap dog, quite ready to begin the day, was perched on his hind legs, his paws resting on the windowsill, the nub of lis tail twitching at the prospect of joining some action in the backyard. It wasn't supposed to be like this. Zack's first thought of the morning was the same as the last he. should remember from the night just past.

Boards of trustees… hospital buybacks… rules on length of 4@ay … policies on who gets admitted and who doesn't… enemies allies… realty trusts… Golden Circles… interlocking @. Directorates… as if the stresses, pressures, and crises of day-to-day nedicine weren't enough.. 1 Perhaps, he mused, the real villain in the piece wasn't Frank, or the Judge, or Norman, or even Ultramed. Perhaps it was his own naivetehis idealistic notions of illness and injury and the healing arts. Perhaps that was what needed overhauling. Emotionally as well as physically drained, he shuffled to the bathroom to shave and shower, pausing to pull a quarter from behind Cheap dog's ear before letting him out. The Wall, he knew, was just a few hours away. Save for the lone librarian, the Ultramed-Davis record room was deserted. With thirty minutes remaining before his appointment with Jack Pearl, Zack had decided to give Toby Nelms's chart one last go-through. Although he still felt numb and deflated from the madness of the previous night, the morning, at least, had gotten off to a decent start. After getting Cheap dog settled on his run, he had chosen a route to the hospital that took him past a broad field of tiger lilies, lavender, and black-eyed Susans.

For years Annie Doucette had allowed scarcely a day to pass without setting fresh flowers on the dining room table and mantel of the Iverson home. During her hospitalization, the family had done its best to repay her in kind. Gathering up an armload bouquet, Zack had amused himself by composing cards he would have liked to have propped up by the vase in her ICU cubicle. To Annie, with deepest apologies. Ultramed… To Annie, my temporary patient, from Don, your temporary doctor. In repayment for your humiliation, heart attack and broken hip. In sharp contrast to the surreal chaos of the early morning hours, the unit had been bright and tranquil. Annie, the Haldol largely out of her system, was fully oriented and even a bit feisty. Although she was sluggish from the analgesia she was receiving for her hip, she had talked in detail of her son and grandchildren, and of Zack's family. Of the thirty-six hours preceding her fall, she remembered nothing, except to reiterate her determination not to be sent to "any death-trap nursing home."

Donald Norman's cookbook cardiology had, for the moment at least, proven adequate, and while Annie's cardiac status remained shaky, it was not critical. All in all, Zack had left the unit sensing that if anyone her age could make it through the ordeal she was facing, Annie Doucette could. The record room librarian, an alert young brunette who was nearing the end of a pregnancy, seemed grateful to have company. Zack signed for Toby's chart and brought it to one of several Formica-walled dictation carrels, The manila folder he set to one side contained the notes and the trickle of articles he had begun to amass on the more obscure complications of the two anesthe ics the boy had received. None of those sources had offered so much as a clue to his bizarre condition.

Word by word, more meticulously even than on previous efforts, he picked through the chart. Family history-unremarkable, past medical history-usual childhood immunizations and diseases, nothing else of consequence, physical exam-normal except for an incarceratedinguirial hernia, operative and anesthesia notes-routine. Nurses' notes, "patient brought into recovery from O. R. awake, alert, and smiling, vital signs normal, no evidence for respiratory depression, pupils equal and reactive, lungs clear."

Remarkable. Absolutely remarkable. Zack read the notes once, and then again. Toby's total stay in the recovery room was less than thirty minutes. He asked for Suzanne's chart. Her anesthe ics and doses, when adjusted for weight, were virtually identical to Toby's, so were her recovery room nurses' notes. Total time in the recovery room, forty-five minutes. The g I'm of an idea began to take root. Zack checked the time.

Thirteen minutes until he met with Pearl. "Excuse me, " he called over to the librarian, "are these records completely computerized? "

"For the last five years, yes, " she said, setting aside the romance saga she was reading. "I think they're working on the five years before that."

"Well, supposing I wanted to get, say, a list of all the gallbladder patients operated on in the last three years?"

"No problem. Cholecystectomy is one of our codes, 3982, I think."

"How about just the ones where Dr. Pearl was the anesthesiologist?"