Richard Mabry - Diagnosis Death

She'd start packing tomorrow night. In a couple of weeks, she'd jam cardboard boxes with the remnants of her life into every available space in her little Ford and set out for a new life, a new chance.

Elena's positive thoughts crashed about her when the phone rang. She looked at the bedside clock. Midnight.

She brought the phone to her ear and held her breath. She expected to hear sobbing, but this time there was none. Only silence.

Finally, when she could stand it no longer, she said, "Hello?" Her voice shook, and she hated herself for it.

No answer.

"Hello?"

The reply came in the same rough whiskey alto as the other calls, but the words were different this time. "I know what you did, and you have to pay. This makes twice."

The night brought no rest. Elena tumbled and tossed, wracked by dreams of faceless women who chased her through dark winding corridors. Before she left her bedroom, she stripped the sweat-soaked linens from the bed and deposited them along with her still-damp pajamas in the laundry hamper.

Elena made coffee and decided to skip breakfast in favor of a donut on the way to the hospital. She was halfway to the front door when the envelope caught her eye. It peeked from the pile of bills and ads she'd chosen to ignore yesterday when she came in. Elena started to pick it up between her thumb and forefinger before she caught herself. Don't be silly. No one is going to fingerprint this. Just open it.

It was like the other envelope-plain, self-sealing, available at a hundred stores-addressed in block capitals. This one bore only a single stamp. She squinted to read the smudged postmark-mailed from the central post office on Monday evening.

Elena ripped the flap and pulled out a single sheet of plain paper. The same block capitals, written in blue ballpoint, spelled out a new message:

THAT'S TWO STRIKES. WILL THERE BE THREE?

Elena made it through the morning on autopilot. Clinic was mercifully light. At noon she took her bowl of soup to a quiet corner of the cafeteria. The bowl was empty when she returned her tray to the moving belt, but she had no recollection of what she'd eaten. All she could think about was "two strikes."

This changed everything. The person who made the phone calls was connected with the circumstances of Chester Pulliam's death. Maybe they were the same person, maybe not, but they were certainly connected. Did Lillian's reach extend to the hospital? Could she know the effect of the cloud cast over Elena's professional reputation by recent events in the ICU? And if Lillian was behind this, how had she managed it?

Elena consulted the large clock that hung over the door of the cafeteria. She had half an hour before she was due in the neurosurgery department's monthly M amp;M conference. She'd been in medicine so long she no longer thought of candy when she heard those initials. No, this was the Morbidity and Mortality Conference, the meeting where the menu centered on complications and death, neither a sweet subject.

One of the "mortality" cases was that of Chester Pulliam. Matney promised that her possible role in the termination of his life support wouldn't come up, but although her attendance was pro forma, it was necessary. Now she had twenty-five minutes to make it across campus for the conference. Ten minutes to the shuttle bus stop, ten or more for the ride to the building that housed neurosurgery, another five to make it to the conference room. No, there was no time for what she wanted to do.

Elena started for the door. First the conference, then the phone call. She promised herself she wouldn't forget it. She dreaded making it, but she had to know. This had to come to an end.

Twenty-seven minutes later Elena opened the door of the neurosurgery conference room a cautious six inches and peered inside. A huge conference table occupied at least two-thirds of the room. A mixture of faculty and residents filled the chairs around it, with Matney at the head. Dr. Clark sat immediately to his right with the department vice chairman, Dr. Bruce Mickey, on Matney's left. The chairman whispered something, and the three men laughed. Elena took the opportunity to ease into the room and slide into a vacant chair along the back of the room.

Two junior faculty members were seated to Elena's right. She wasn't particularly trying to eavesdrop, but their whispers came through as though channeled through a megaphone.

"Did you hear about Dr. Matney?"

"Yeah. Dunston's leaving, and Matney's the prime candidate to succeed him as dean. The Search Committee's giving him the once-over right now."

The first doctor looked around. Elena casually directed her gaze to the bound journals lining the walls. Satisfied, he continued. "Matney's already given the word to the faculty. He wants this department squeaky clean. Anything that might look bad, sweep it under the rug or deep-six it some way. If it could bring attention, don't do it."

"I know. He caught me in the surgeon's lounge and told me to stop giving a particular IV med to patients with cerebral edema because that was off-label usage."

"Man, I'll be glad-"

"Let's get started." Matney's eyes swept the room. All conversation stopped as though someone had hit a "mute" button. The chairman leaned back in his chair, apparently relaxed and comfortable.

"Gershon?" This was a first-year resident, who presented the case of a patient who'd developed an infection at the operative site after an otherwise uneventful craniotomy. Elena knew that the most serious neurosurgical complications were vascular- either hemorrhage or obstruction to circulation. This one was unexpected but not what she'd consider major. Indeed, the patient responded well to antibiotics and had no further problems. Nevertheless, Matney spent fifteen minutes questioning the resident and his staff surgeon about how they might have prevented this postoperative infection.

Elena felt her stomach doing flip-flops. If Matney handled the morbidity portion of the conference this way, what would he do when the mortality discussions started? She tried to dry her palms on her white coat, but it didn't seem to help. Her throat was parched, her heart was in her throat. She hardly heard Matney's next words.

"Dr. Neely, tell us about Mr. Pulliam."

This was the resident whose name Elena hadn't been able to recall, the one who had pronounced Chester Pulliam dead. He presented the facts in a monotone more appropriate for delivering an annual report to stockholders than a description of the death of a human being. Elena wondered if this was a coping mechanism adopted early in their training by neurosurgeons because they dealt every day with matters of life and death. She hoped she'd never become that callous about the loss of a human life. Then the irony of that thought brought her up short.

Neely ground to a halt with, "The patient was maintained on life support, but showed no effective respiratory efforts and required IV dopamine to maintain his blood pressure. He had a diffuse dysrhythmia on EEG, showed a positive Babinski reflex, and we observed early decorticate rigidity developing. We discussed withdrawal of life support with his wife. Subsequently that was done and he expired quietly."

That was it. No mention of an unidentified person disconnecting the respirator, or of the questionable DNR order. No finger-pointing by Clark or Matney. Instead, Clark encouraged the residents to maintain a high index of suspicion for arteriovenous malformations, the snake-like tangle of blood vessels around the brain that had ruptured and sent Chester Pulliam to his death. For the first time he looked at Elena and said, "Dr. Gardner, who's joined us today, did all the right things in getting immediate treatment for Mr. Pulliam. Unfortunately, his intracranial bleed wasn't a survivable one. That's why it's imperative to find these before they rupture."