Robin Cook - Fatal Cure

"And far too many laboratory tests," Beaton said.

"Too many diagnostic tests as well," Caldwell said.

David stared at the three administrators in disbelief. Each returned his stare with impunity. They were a tribunal sitting in judgment. It was like the Inquisition. He was being tried for economic medical heresy, and not one of his inquisitors was a physician.

"We want to remind you that you are dealing with a patient who has been treated for metastatic prostate cancer," Kelley said.

"We're afraid you've already been too lavish and wasteful with your orders," Beaton said.

"You have a history of excessive use of resources on three previous patients who were clearly terminal," Caldwell said.

David struggled with his emotions. Since he'd already been questioning his competence as a result of the three successive deaths, he was vulnerable to the administrators' criticism. "My allegiance is to the patient," David said meekly. "Not to an organization or an institution."

"We can appreciate your philosophy," Beaton said. "But such a philosophy has led to the economic crisis in medical care. You must expand your horizons. We have an allegiance to the entire community of patients. Everything cannot be done to everybody. Judgment is needed in the rational use of limited resources."

"David, the fact of the matter is that your use of ancillary services far exceeds norms developed by your fellow physicians," Kelley told him.

There was a pause. David wasn't sure what to say. "My worry in these particular cases is that I'm seeing an unknown infectious disease. If that is the case, it would be disastrous not to diagnose it."

The three medical administrators looked at each other to see who would speak. Beaton shrugged and said: "That's out of my expertise; I'm the first to admit it."

"Mine too," Caldwell said.

"But we happen to have an independent infectious disease consult here at the moment," Kelley said. "Since CMV is already paying him, let's ask him his opinion."

Kelley went out and returned with both Dr. Martin Hasselbaum and Dr. Clark Mieslich. Introductions were made. Dr. Hasselbaum was asked if he thought that David's three deceased patients and Mr. Eakins might have been afflicted by an unknown infectious disease.

"I sincerely doubt it," Dr. Hasselbaum said. "There's no evidence whatsoever that they had an infectious disease. All three had pneumonia, but I feel the pneumonia was caused by generalized debility. In all three cases the agent was a recognized pathogen."

Kelley then asked both consults what form of treatment they thought should be given to Jonathan Eakins.

"Purely symptomatic," Dr. Mieslich said. He looked at Dr. Hasselbaum.

"That would be my recommendation as well," Dr. Hasselbaum said.

"You both have also seen the long list of diagnostic tests that have been ordered by Dr. Wilson," Kelley said. "Do you think any of these tests are crucial at this time?"

Dr. Mieslich and Dr. Hasselbaum exchanged glances. Dr. Hasselbaum was first to speak: "If it were my case I'd hold off and see what happened. The patient could be normal by morning."

"I agree," Dr. Mieslich said.

"Well then," Kelley said, "I think we all agree. What do you say, Dr. Wilson?"

The meeting broke up amid smiles, handshakes, and apparent amity. But David felt confused and humiliated, even depressed. He walked back to the nurses' station and canceled most of the orders he had written for Jonathan. Then he went in to see Jonathan himself.

"Thanks for having so many people come and examine me," Jonathan said.

"How do you feel?" David asked.

"I don't know," Jonathan said. "Maybe a little better."

When David got back to the autopsy room, Angela was just cleaning up. David's timing had been good. He helped return Mary Ann's body to the morgue. David noticed that Angela wasn't eager to talk about her findings. He practically had to grill her for answers.

"I didn't find much," Angela admitted.

"Nothing in the brain?" David asked.

"It was clean grossly," Angela said. "But we'll have to see what the microscopic shows."

"Any tumor?" David asked.

"I think there was a tiny bit in the abdomen," Angela said. "Again, I'll have to wait for the microscopic to be sure."

"So nothing jumped out at you as a cause of death?" David asked.

"She did have pneumonia," Angela said.

David nodded. He already knew that.

"I'm sorry I didn't find more," Angela said.

"I appreciate that you tried," David said.

As they drove home, Angela could tell that David was depressed. He'd only been answering questions in monosyllables.

"I suppose you're upset because I didn't find much on the autopsy," Angela said, pausing before she got out of the car.

David sighed. "That's just part of it," he said.

"David, you are a wonderful, talented doctor," Angela said. "Please stop being so hard on yourself."

David then told her about being hauled before the tribunal by Kelley. Angela was livid. "The nerve," she said. "Hospital administrators should not become involved in treatment."

"I don't know," David said with a sigh. "In some ways they're right. The cost of medical care is a problem. But it's so confusing when you get down to specifics with an individual patient. But the consults did side with the administrators."

At dinner, David discovered he wasn't hungry; he merely pushed his food around the plate. To make matters worse, Nikki complained that she didn't feel well.

By eight o'clock, Nikki started to sound congested and Angela took her upstairs for her respiratory therapy. When it was over, Angela found David sitting in the family room. The television was on but David wasn't watching; he was staring into the fire.

"It might be best to keep Nikki home from school tomorrow," Angela said. David didn't answer. Angela studied his face. For the moment she didn't know who she was more concerned about: Nikki or David.

When Angela first opened her eyes at the sound of the alarm, she was disappointed not to find David next to her. Getting up she pulled the drapes. The overcast skies held the promise of showers.

Angela went down to look for David. She found him sitting in the family room.

"Have you been up for long?" Angela asked, trying to sound cheerful.

"Since four," David said. "But don't be alarmed. I think I feel a bit better today." He gave Angela a half smile.

Although Angela was still concerned about David, she was pleased with Nikki's respiratory status. Nikki woke with no congestion. And she'd again made it through the night with no nightmares. Even Angela had to admit that David might have been right about the benefits of his silly prank with the Halloween masks.

Unfortunately, Angela herself had had a nightmare. It was a dream in which she came home from shopping, carrying bags of groceries, only to find the kitchen drenched in blood. But it wasn't dried blood. It was fresh blood that was running down the walls and pooling on the floor.

After Nikki's respiratory treatment, Angela listened carefully to her chest. It was definitely clear. To Nikki's delight, Angela told her she could go to school.

Despite the possibility of rain, David insisted on riding his bike to work. Angela didn't try to talk him out of it. She felt it was encouraging that he was able to muster the enthusiasm for it.

After dropping Nikki off, Angela drove on to the lab, eager to get to work. Mondays were usually busy since there was a pile-up of laboratory work from the weekend. Breezing into her office, Angela had her coat on its hanger before she noticed Wadley. He'd been standing motionless near the connecting door.

"Good morning," Angela said, again trying to sound cheerful. She hung her coat up and turned to face her chief. It was immediately apparent he wasn't happy.