Peter Clement - Mortal Remains

He shook his head no, wishing she hadn’t chosen him to grandstand on. But he was imminently grateful to her for coming in and getting things going, and if he had to endure a few minutes of being a teaching specimen, so be it. Besides, it wasn’t entirely a waste. The latest rage in teaching hospitals was for the teachers to take a turn on the other side of the white coat. He’d let the residents know he’d had his, thank you very much, when he got back to Buffalo.

“So, his lack of risk factors, along with the absence of a pulsatile mass, means an aortic aneurysm is unlikely,” she continued. “The patient being male, what’s left that’s hollow?”

“GI!” responded a bearded man at the back.

“Sold!” Earl said, figuring it was time to wrap up the bidding on his diagnosis.

But Melanie hadn’t finished putting on her show. “Right. And since there’s no vomiting, we can assume the problem doesn’t lie in the upper gastrointestinal tract, which leaves us with?”

“Lower,” her audience said in unison.

Get on with it, Earl nearly told her, his innards clamping down on themselves again.

“Now I know this thought process sounds oversimplistic, but it’s what should have zipped through your heads in the first few seconds you saw this patient, and everyone’s focus ought to have been on the lower GI for a nonsurgical problem from the get-go. Okay, what’s the differential? But this time start with the most probable. Don’t bother me with stuff about tumors, obstruction, ischemia, or chronic things like inflammatory bowel disease. And for God’s sake don’t begin with rare genetic disorders like porphyria. I hate having to look up those damn metabolic pathways.”

A collective chuckle came from the group.

“Enteritis, colitis, or both,” one of the young men said.

“Very good. The probable cause?”

“Viral or bacterial contamination from food,” he replied.

“Which bacteria?”

“ Campylobacter jejuni , salmonella, shigella.”

“Treatment?”

“Hydration, electrolyte management, particularly potassium replacement, Cipro, and painkillers!” He spoke with the certainty of someone on a roll.

Yes! Earl wanted to yell out. You can replace peach-fuzz as my doctor.

“Not so fast,” Melanie said. “Is there any danger in giving ciprofloxacin at this point?”

Oh, Melanie, he wanted to shout, surely old Earl Garnet didn’t have to be treated by the book. Come on, give the Cipro. As physician to physician. Cut corners.

The bearded resident seemed at a loss for words.

“Any reason to wait for stool culture results before treating?” Melanie prompted.

The man stroked his chin as if contemplating a chess move, then shrugged.

Melanie searched the crowd for any other takers. There were none. “Okay, here’s the teaching nugget of this case. The severity of Dr. Garnet’s pain plus an apparent delay in the onset of the inevitable diarrhea makes me think this might be an organism other than the more common ones you listed. With them, the diarrhea usually follows closely on the heels of the pain. But with some of the enterohemorrhagic E. coli , where toxins are the culprit, they need time to work, and there can be the sort of delay we see here. In other words, the agent infecting Dr. Garnet may be none other than E. coli 0157:H7 , which can not only cause a hemorrhagic colitis, but in 10 percent of cases, introduce toxins which attack the kidneys to produce a hemolytic uremic syndrome. The latest evidence suggests antibiotics may actually increase the risk of complications, so we hold the Cipro.”

There wasn’t a round of applause, but the appreciative nods as her audience dispersed and returned to their various duties were as good a stamp of approval as a teacher could get for first-rate bedside teaching. Earl had to admit he’d not heard of the subtle nuance she was making, but it made sense, and her zeroing in on it impressed him,

“Hope you didn’t mind me putting you through that,” she said, while checking the IV bag flowing into his arm – normal saline with an added dose of potassium – “but I wanted to set them straight after the inexcusable delay they put you through.”

Be gracious, he told himself. “Hey, our residents are the same until we whip them into shape. You’ve nothing to apologize for, and thank you again for getting out of bed.” And since he had her attention: “Melanie, I’ve also been trying to call you to clear up a misunderstanding-”

“Now you just stay quiet, and I’ll have you comfortable in minutes.” She pulled a syringe out of her lab pocket, stuck it in the side portal of his IV line, and began to push in the plunger. “No allergies I take it?”

“None. What are you giving me. Demerol?”

“You, my friend, get the big M .”

“Morphine?”

She nodded.

But morphine, powerful analgesic that it was, doctors seldom used for acute abdominal pain in ER. It could obtund consciousness to the point of suppressing respiration and cause serious drops in blood pressure. Neither of which was a good thing where issues such as staying awake enough to keep breathing or avoiding aspiration of vomit or fighting a low blood pressure from dehydration were concerned. Of course there were exceptional cases, but he didn’t want to be one of them. “Listen, Melanie, I’m not that bad. Don’t give me special treatment – Whoa!”

The potent opiate affected him immediately, taking away not only his abdominal spasms but every ache and pain he had, physical or emotional. He felt his brain slip into a warm puddle, where it floated without a care in the world.

“I’ll make sure the nurses keep you well topped off,” said a voice from the other side of the universe.

Must be God talking. Sounded like his kind of woman, one who knew her business.

Thursday, November 22,

11:45 A.M.

Hampton Junction

Mark stood on the back porch, sipping a cup of coffee that had come from the bottom of the pot. Along the horizon, a gray, humpbacked line of clouds strained toward the east, dragging their shaggy tendrils over the hills. The cold wet aroma of snow hung in the air.

He’d spent the morning in his office reading his mail and answering a seemingly endless stream of calls from patients. Most were trivial problems easily answered.

Between calls he’d puzzled over why Charles Braden had invited Lucy and him to his home. And stared at the ceiling to the sound of creaky floorboards as Lucy prowled around her room. What was up with her? When she got back from shopping last night, she’d prepared dinner and welcomed Victor with open arms. Then she’d kept them entertained throughout the meal with stories of warlords, strange animals, and field hospital hijinks. Afterward, Victor sat down at the piano and led them through the highlights of great Broadway shows. They belted out the tunes they knew and danced to the ones they didn’t.

Victor had left in high spirits, yet as soon as he was out the door, she’d said she was exhausted and gone directly to bed.

This morning he’d wakened to the sounds of her in the kitchen and the smell of fresh coffee, but when he came down to join her for breakfast she retreated back upstairs, taking her cup with her, apologizing profusely that she had a ton of correspondence to answer and job applications to send out. “After all, by next July, I plan to be a working woman again.”

Why was she avoiding him? From the creaking of the floorboards, she’d seemed to be doing more pacing than writing.

The phone rang for the umpteenth time, bringing him back inside.