Richard Mabry - Diagnosis Death

The most obvious action would be to disconnect the respirator from his endotracheal tube. Two or three minutes, and it would be over.

She scanned the medication cart. Pills? It would be difficult to get them down the feeding tube. Something injected? The IV had been removed, but there were needles and syringes on Ann's cart along with vials of various medications. One intramuscular injection would release Chester Pulliam from his prison.

She looked down at the frail figure on the bed and located the pulsations of his carotid artery. Enough pressure on one spot-a spot she could easily find-and his heart would slow and stop.

Elena knew how to spare Chester from a living death. If she did that, Erma Pulliam would be spared too-spared the guilt that comes from making the decision that ends the life of a loved one. Sure, she'd grieve for a while, but eventually she'd move on. She wouldn't be tied for who knows how long to a husband whose brain no longer functioned, whose body shriveled with contractures and wept with bedsores.

Mrs. Pulliam was waffling. Elena recognized all the signs. And delaying the decision would just bring about a host of problems. Chester would have recurring kidney infections because of his catheter. Despite frequent suctioning through his tracheotomy, pneumonia would finally come. The staff would turn him frequently, but eventually he'd develop decubitus ulcers-ugly sores that smelled foul and ran pus, poisoning his system. He'd shrink to a husk of the man Erma Pulliam had known. And thanks to the miracles of modern medicine, his life-if you could call it life-would go on.

Elena could prevent all that. And that knowledge was what made her heart sink, as she stood alone at the bedside, pondering what to do.

Twenty minutes later, Elena tapped the keys of a computer in the hospital library to call up the last of the articles and research papers she needed. She snatched the papers from the printer as quickly as it spit them out, turned, and moved toward the elevator. Had she done the right thing? Well, what was done was done. From here on, it was out of her hands.

Her pager went off as she stepped off the elevator. Elena pushed through the doors of the ICU and stopped. Something was going on in Chester Pulliam's room. A resident, one whose name she couldn't recall, bent over the bed. He listened for a few moments, then straightened and looped his stethoscope around his neck. The nurse, Ann, stood next to him. He murmured something to her. She nodded assent and pulled the sheet over Pulliam's face.

As the doctor edged through the door, he saw Elena. "I didn't expect you to be around for this."

She plucked at his sleeve, but he kept walking. She hurried after him, matching his long strides. "What do you mean? I got a page and came in here to use the phone."

He ducked into the head nurse's office and closed the door behind them. "We told Mrs. Pulliam it was time to take him off life support, but she couldn't bring herself to do it. The nurses saw you talking with her this morning. They figured you told her about Mark."

"I did, but the decision still had to be hers."

He grunted. "Pulliam's nurse had to help when one of the other patients in the unit went sour. Half an hour later, when Ann went in to check him, Pulliam's respirator was turned off. His wife was at his bedside, holding his hand."

Elena couldn't believe what she was hearing. "Maybe Mrs. Pulliam decided to do it herself. Say good-bye, flip the switch, sit there with him while he died."

"No, she said it was off when she returned to the room. The nurse figured you did it to save Mrs. Pulliam from having to make the decision. That's the way I see it too." He frowned as his pager beeped. "I'm going to sign it out as death due to his stroke." He thumbed the pager button, looked at the display, grimaced. "For the record, I think it was probably all for the best. I saw the DNR order you wrote on his chart today. I hope Dr. Clark is okay with it."

The resident rose from his chair. "Gotta answer this page. See you around."

"Wait!" she called. But the young doctor was already out the door, on his way to handle the next emergency.

Elena slumped into a chair and buried her head in her hands. What next?

Elena stumbled through her clinic duties that afternoon. Time after time she had to ask patients to repeat themselves, their answers drowned out by the words that still rang in her ears: "I saw the DNR order you wrote on his chart today."

"Mrs. Murchison," Elena said, "Your blood pressure is creeping up a bit, but so is your weight. Are you following that diet I prescribed?"

"Well, doctor…"

Elena knew what the answer was before the woman was halfway through her detailed justification for ignoring her diet. High blood pressure was truly the silent killer. Until the symptoms were severe enough-headaches, dizziness, shortness of breath-people tended to ignore the warnings of their doctors. Mrs. Murchison was no exception.

"I'm going to ask the nutritionist to talk with you again. Meanwhile, let's add this to the blood pressure medication you're already on." Elena filled in the prescription as she talked. "Let's see you back in two weeks. I want you to be two pounds lighter by then. Will you try?"

Mrs. Murchison left, trailing promises and good intentions behind her. Elena wrote a note and tossed the chart into the basket beside her desk. She wondered if she'd be here in the clinic in two weeks when Mrs. Murchison returned.

The clinic nurse stuck her head through the door. "That's your last patient."

"Thanks, Mary." Elena sat for a moment, torn between going home to lick her wounds and picking up the phone to make a call that would either resolve her problem or make it much worse. The strident bleat of her pager put an end to her indecision.

The number included the medical school prefix. She felt that she should recognize it, but the identity danced in her head just out of reach. She dialed it, and the voice that answered reminded her why it seemed familiar. It was one she'd heard on a daily basis while Mark was in the ICU.

"Dr. Matney."

"This is Elena Gardner. You paged me?"

The chairman of neurosurgery cleared his throat. "Elena, I believe we need to talk. How soon can you come to my office?"

"I'm at St. Paul, but I can be there in fifteen minutes. Is that okay?"

"Come as soon as you can. We'll be waiting."

Dr. Matney's call set alarm bells ringing in Elena's head. His use of the word "we" increased the cacophony a dozen-fold. What "we"? Who else would be waiting for her? She thought she knew, and the prospect was far from pleasing.

No condemned man ever walked his last mile any more slowly and unwillingly than Elena trudged down the hallway to enter Dr. Bruce Matney's outer office. His secretary gave two sharp raps on the closed door of the chairman's inner sanctum, opened it, and motioned Elena in. The closing of the door behind her made Elena want to bolt, but there would be no escape from this meeting.

It was his office, his meeting, and Matney held center stage. He sat behind his desk, flanked by Dr. Amy Gross on his right and Dr. James Clark on his left. Matney motioned Elena to the straight chair across from him.

"Elena, thank you for coming."

She wanted to say, "I had no choice," but decided that silence had served her well before so it was worth a try here as well. She simply nodded.

Matney picked up a thick manila folder. "This is Chester Pulliam's chart."

Elena felt her heart creep into her throat. Droplets of sweat trailed down her backbone. She hunched her shoulders, but the muscles remained tense as bowstrings.

Clark took the chart from Matney's hand and flipped it open. This time the page was marked with a paper clip, but otherwise the feeling of deja vu was complete. "I believe I intimated that Chester Pulliam had virtually no hope of recovery. I know you communicated this to his wife, and frankly, I appreciate that. It's difficult to break this kind of news. But there are some questions about the way he met his end, and we think you can answer those questions." He tapped the page with a manicured fingernail. "Here is a DNR order you wrote-an order about which I knew nothing. And Pulliam was found dead, disconnected from his respirator, immediately after you were alone in his room. The inference is obvious."