Crisis (3 page)

"How can he live with her? She's such a pain in the ass, and he seems like quite a refined gentleman." Leona had observed the Stanhopes in the office on a couple of occasions.

"I imagine there are benefits. I have a sense she is the one with the money, but who knows. People's private lives are never what they seem, including my own, until recently." He gave Leona's thigh a squeeze.

"I don't know how you have such patience with such people," Leona marveled. "No pun intended."

"It's a struggle, and between you and me, I can't stand them. Luckily, they are a distinct minority. I was trained to take care of sick people. Hypochondriacs to me are the same as malingerers. If I had wanted to be a psychiatrist, I would have studied psychiatry."

"When we get there, should I wait in the car?"

"It's up to you," Craig said. "I don't know how long I'll be. Sometimes she corners me for an hour. I think you should come in. It would be boring to sit in the car."

"It will be interesting to see how they live."

"Hardly the average couple."

The Stanhopes lived in a massive, three-story, Georgian-style brick house on a sizable wooded lot near the Chestnut Hill Country Club in an upscale area of Brighton, Massachusetts. Craig entered the circular drive and pulled up to the front of the building. He knew the route all too well. Jordan had the door open as they mounted the three steps. Craig had the black bag; Leona carried the ECG machine.

"She is upstairs in her bedroom," Jordan said quickly. He was a tall, meticulous man dressed in a dark green velvet smoking jacket. If he marveled at Craig and Leona's formal attire, he didn't let on. He held out a small plastic vial and dropped it in Craig's hand before turning on his heel.

It was the free sample bottle of Zoloft Craig had given Patience that morning. Craig could see immediately that one of the six pills was missing. Obviously, she had started the medication earlier than Craig had suggested. He pocketed the vial and started after Jordan. "Do you mind if my secretary comes along?" Craig called out. "She can possibly lend me a hand." Leona had demonstrated a few times in the office her willingness to help out. Craig had been impressed by her initiative and commitment from the start, long before he thought of asking her to a social event. He was equally impressed that she was taking night courses at Bunker Hill Community College in Charlestown, with the idea of eventually getting some sort of medical degree as a technician or nurse. For him, it added to her appeal.

"Not at all," Jordan responded over his shoulder, waving for them to follow. He had started up the main staircase that skirted the Palladian window above the front door.

"Separate bedrooms," Leona whispered to Craig as they hurried after Jordan. "It kind of defeats the purpose. I thought that was only in old movies."

Craig didn't respond. They quickly descended a long carpeted hallway and entered the feminine master suite upholstered in a square mile of blue silk. Patience, her eyelids heavy, was lying in a king-size bed, semi-propped up with overstuffed pillows. A servant in a demure French maid's outfit straightened up. She had been holding a moist cloth against Patience's forehead.

With a quick glance at Patience and without saying a word, Craig rushed over to the woman, dropped the bag on the bed next to her, and felt for a pulse. He snapped open the bag and pulled out his blood-pressure cuff and stethoscope. As he wrapped the cuff around Patience's right arm, he barked to Jordan: "Call an ambulance!"

With only a slight elevation of his eyebrows to indicate he had heard, Jordan went to the nightstand phone and dialed 911. He gave the servant woman a wave of dismissal.

"Good Lord!" Craig murmured as he tore off the cuff. He snapped the pillows from behind Patience's body and her torso fell back onto the bed like a rag doll. He yanked down the covers and pulled open her negligee, then listened briefly to her thorax with his stethoscope before motioning to Leona to give him the ECG machine. Jordan could be heard speaking with the 911 operator. Craig fumbled to unsnarl the ECG leads and quickly attached them with a bit of conducting jelly.

"Is she going to be all right?" Leona asked in a whisper.

"Who the hell knows," Craig answered. "She's cyanotic, for Christ's sake."

"What's cyanotic?"

"There's not enough oxygen in her blood. I don't know if it's because her heart isn't pumping enough or she's not breathing enough. It's one or the other or both."

Craig concentrated on the ECG machine as it spewed out a tracing. There were only little blips, widely spaced. Craig tore off the output strip and took a quick, closer glance at it before jamming it into his jacket pocket. He then snapped the leads off Patience's extremities.

Jordan hung up the phone. "The ambulance is on its way."

Craig merely nodded as he rapidly rummaged in his bag and pulled out an Ambu breathing bag. He placed the mask over Patience's nose and mouth and compressed the bag. Her chest rose easily suggesting good ventilation.

"Could you do this?" Craig asked Leona as he continued to ventilate Patience.

"I guess so," Leona said hesitantly. She squeezed between Craig and the headboard and took over the assisted breathing.

Craig showed her how to maintain a seal and keep Patience's head back. He then glanced at Patience's pupils. They were widely dilated and unreactive. It wasn't a good sign. With the stethoscope, he checked Patience's breath sounds. She was being aerated well.

Back in his black bag, Craig pulled out the assay kit for testing for the biomarkers associated with a heart attack. He tore open the box and pulled out one of the plastic devices. He used a small, heparinized syringe to get some blood from a major vein, shook it, and then put six drops into the sample area. He then held the device under the light.

"Well, that's positive," he said after a moment. He then haphazardly tossed everything back into his bag. "What is positive?" Jordan asked.

"Her blood is positive for myoglobin and troponin," Craig said. "In layman's terms, it means she's had a heart attack." With his stethoscope, Craig ascertained that Leona was ventilating Patience appropriately.

"So your initial impression was correct," Jordan commented.

"Hardly," Craig said. "I'm afraid I have to say, she is in a very bad situation."

"I was trying to communicate as much on the phone," Jordan said stiffly. "But at the moment, I was referring to the heart attack."

"She is worse off than you led me to believe," Craig said as he got out some epinephrine and atropine, along with a small bottle of intravenous fluid.

"I beg your pardon. I was quite clear she was progressively getting worse."

"You said she was having a little trouble breathing. Actually, she was hardly breathing at all when we got here. You could have let me know that. You said you believed she was rather blue, whereas I find her totally cyanotic." Craig deftly started an intravenous infusion. He taped the needle in place and gave the epinephrine and atropine. He hung the small IV bottle from the lampshade with a small S hook he had made for that specific purpose.

"I was doing the best I could to communicate to you, doctor."

"I appreciate that," Craig said, holding up his hands in a conciliatory gesture. "I'm sorry. I don't mean to be critical. I'm just concerned about your wife. What we need to do now is get her to the hospital as quickly as we can. She needs to be ventilated with oxygen, and she needs a cardiac pacer. On top of that, I'm certain she is acidotic and must be treated for it."

The undulating sound of the approaching ambulance could be heard in the distance. Jordan left to go downstairs to let in the emergency technicians and direct them up to Patience's room.

"Is she going to make it?" Leona asked as she continued compressing the Ambu bag. "She doesn't look quite as blue to me."

"You're doing a great job with that breathing bag," Craig responded. "But I'm not optimistic, since her pupils haven't come down, and she's so flaccid. But we'll know better when we get her over to Newton Memorial Hospital, get some blood work, get her on a respirator and a pacer. Would you mind driving my car? I want to ride in the ambulance in case she arrests. If she needs CPR, I want to do the chest compressions."

The EMTs were an efficient team. It was a man and a woman who obviously had worked together for some time, since they anticipated each other's moves. They swiftly moved Patience to a gurney, brought her downstairs, and loaded her into the ambulance. Within just a few minutes of their arrival at the Stanhope residence, they were back on the road. Recognizing a true emergency, they had the siren screaming and the woman drove accordingly. En route, the male EMT phoned ahead to Newton Memorial to advise them of what to expect.

Patience's heart was still beating, but barely, when they arrived. A staff cardiologist whom Craig knew well had been summoned, and she met them on the unloading dock. Patience was rolled inside with dispatch, and an entire team began to work on her. Craig told the cardiologist what he could, including the results of the biomarker assay confirming the diagnosis of myocardial infarction, or heart attack.

As Craig had anticipated, Patience was first put on a respirator with one hundred percent oxygen followed by an external pacemaker. Unfortunately, it was quickly confirmed that she then had the problem of PEA, or pulseless electrical activity, meaning the pacemaker was creating an image on the electrocardiogram but the heart was not responding with any beats. One of the residents climbed up onto the table to start chest compressions. Blood work came back and the blood gases were not bad, but the acid level was close to the highest the cardiologist had ever seen.

Craig and the cardiologist looked at each other. Both knew from experience that PEA had a dismal outcome with a hospital inpatient, even when caught quickly. The situation with Patience was far worse, since she had come in by ambulance.

After several hours of attempting all possible efforts to get the heart to respond, the cardiologist took Craig aside. Craig was dressed in his formal shirt, complete with bow tie still in place. Blood spatter adorned the upper part of his right arm, and his tuxedo jacket hung on a spare IV pole against the wall.

"It must have been extensive cardiac muscle damage," the cardiologist said. "It's the only way to explain all the conduction abnormalities and the PEA. Things might well have been different if we had been able to start on her a bit sooner. From your description of the time course, I imagine the size of the initial infarct significantly grew."

Craig nodded. He looked back at the team that was still doing cardiopulmonary resuscitation on Patience's slim frame. Ironically, her color had returned to near normal with the oxygen and the chest compressions. Unfortunately, they had run out of things to try.

"Did she have a history of cardiovascular disease?"

"She had an equivocal stress test a few months ago," Craig said. "It was suggestive of a mild problem, but the patient refused any follow-up studies."

"To her detriment," the cardiologist said. "Unfortunately, her pupils have never come down, suggesting anoxic brain damage. With that in mind, what do you want to do? It's your call."

Craig took in a deep breath and let it out noisily as a reflection of his discouragement. "I think we should stop."

"I agree one hundred percent," the cardiologist said. She gave Craig's shoulder a reassuring squeeze, then walked back to the table to tell the team it was over.

Craig got his tuxedo jacket and walked over to the ER desk to sign the paperwork indicating the patient was deceased and that the cause was cardiac arrest following myocardial infarction. Then he went out into the emergency room waiting area. Leona was seated among the sick, the injured, and their families. She was flipping through an old magazine. Dressed as she was, she appeared to Craig like a nugget of gold among nondescript gravel. Her eyes rose up as he approached. He could tell she read his expression.

"No luck?" she said.

Craig shook his head. He scanned the waiting area. "Where is Jordan Stanhope?"

"He left over an hour ago."

"Really? Why? What did he say?"

"He said he preferred to be at home, where he would await your call. He said something about hospitals depressing him."

Craig gave a short laugh. "I guess that's consistent. I always thought of him as a rather cold, odd duck who was just going through the motions with his wife."

Leona tossed aside the magazine and followed Craig out into the night. He thought about saying something philosophical about life to Leona but changed his mind. He didn't think she'd understand, and he was worried he wouldn't be able to explain it. Neither spoke until they got to the car.

"Do you want me to drive?" Leona asked.

Craig shook his head, opened the passenger door for Leona, then walked around and climbed in behind the wheel. He didn't start the car immediately. "We obviously missed the concert," he said, staring out through the windshield.

"To say the least," Leona said. "It's after ten. What would you like to do?"

Craig didn't have any idea. But he knew he had to call Jordan Stanhope and wasn't looking forward to it.

"Losing a patient must be the hardest thing about being a doctor," Leona said.