Critical Judgment (1996) (17 page)

The country club, he thought. That was it. That was the fucking problem. All the country clubs set up all over the country to remind folks like him they were poor, worthless failures, not good enough now, not good enough ever. But, hey, don’t forget that the good folks at the country club had let him in the elegant clubhouse once for three whole weeks … until he had finished painting it!

He gunned the engine of his Chrysler, a beast with 170,000 miles on the odometer and its second rebuilt engine under the hood. His vision was blurred, his brain on fire. What a rotten existence—what had he ever done to deserve this? Nothing. Absolutely nothing. He sped off in a shower of gravel, then screeched to a stop, opened the door, and heaved up the contents of his stomach. That was the end, he vowed, coughing and sputtering. He had thrown up for the last time. They could step all over him, they could take away his job for no good reason, but they couldn’t break him. He was a
goddamn Marine, for chrissake, and if Marines knew nothing else, they knew how to fight back.

The beautiful people had the money and the power and the Jags and the houses and the diamonds and the country clubs. He had a twelve-year-old tank of a car and the spirit of a Marine. No contest!

Fifty-five … sixty … sixty-five …

The Chrysler began to shudder. He gripped the wheel tightly and pressed his foot to the floor. The headache was as horrible as ever, but this time, at least, he didn’t care. The country-club people had done this to him. Now it was his turn.

Seventy … seventy-five …

The cross streets flew by. The trees and telephone poles were blurs. The car was shaking mercilessly. An acrid smoke began billowing in around him. He was off the seat now, his right leg rigid, his foot jammed on the accelerator. Mission: enemy destruction.
Target in sight, sir
.

“From the halls of Montezuma, to the shores of Tripoli …”

He barreled off the road, across a stretch of grass, and up a small hill. The fence, shielded in green vinyl windbreaker, was just ahead.
No problem, sir
.

Eighty … eighty-five …

“We will fight our country’s battles in the air, on land, and sea.…”

At last the pain in his head was gone. At last the hideous taste had left his mouth. At last he had stopped taking the punishment lying down.

The screeching of the engine … the crunch of metal on metal … the screams … more screams … the crash … the pain … the blackness …

Mission accomplished, sir.…

Seated at her desk in the on-call room, Abby studied the results from the first three NIWWs on whom she had ordered cadmium levels. All were negative. One of the three, a farmer named Thomas McElroy, had come to see her. His complaints were a lack of energy and a chronic cough that had not responded to two courses of antibiotics. His physician was George Oleander. Abby had ordered the cadmium level, then, on a hunch, she ordered a test for organophosphates as well. Organophosphate
was a neurotoxin, commonly used in gaseous form as a chemical weapon during World War II. But it was also a component in many fertilizers. Apparently, Thomas McElroy had somehow gotten exposed to it.

Trace positive
. She had no clear idea what, if anything, that meant. The tongue-in-cheek law taught to medical students was never to order a test unless you were ready to have it come back abnormal. The corollary to that law was that the best response to any abnormal blood test was to repeat it.

Abby decided that a better approach would be to set the whole matter in George Oleander’s lap. If, in fact, Thomas McElroy’s symptoms
were
due to organophosphate poisoning, the first definitive diagnosis for one of her NIWWs had been found. And it would
not
be cadmium. She peeked out to be sure that the ER was still quiet. Sundays often started peacefully, with families in church or beginning their days slowly. But with none of the medical offices open, and minimal coverage for each practice, the afternoons and evenings were predictably busy. At the moment things were very quiet. She was heading back to the phone when the wall-mounted intercom sounded.

“Dr. Dolan,” the receptionist said, “Dr. Oleander’s on line two.”

“This is one efficient hospital,” Abby muttered, punching the line open. “George, hi. I was just about to call you.”

“To explain yourself, I hope.”

“What?”

“I just got copies of some laboratory tests you sent off on two of my patients, Carl Standon and Tom McElroy.”

“Yes.”

“Abby, what on earth are you doing ordering cadmium levels on these people? And how many more patients have you ordered them on?”

“Just one other. I don’t understand what the problem is.”

“Well, it’s time you did. Just what were your indications for ordering these studies?”

“The symptoms were different for each patient. I’ve been reading a lot about cadmium toxicity and—”

“I am telling you here and now that I don’t want extraneous tests ordered on my patients without consulting me. And I can tell you also that most of the other doctors on the staff here feel exactly the way I do.”

Abby felt her self-control begin to unravel. She glanced about the small office and wondered if what Lew had told her about bugs and cameras could possibly be true.

“I don’t feel they were extraneous,” she said stonily. “I also ordered an organophosphate level on Mr. McElroy, and that was positive.”

“McElroy’s a farmer. Every summer he uses that damn stuff, and every summer he gets exposed, and every summer I treat him if his levels are high enough to warrant it. It’s not
that
test I’m upset about, and you know it. If you’ve set about trying to cause trouble for Colstar and this town, you may find yourself looking for a job.”

“Don’t threaten me, George. And please don’t speak to me in that tone of voice. I did what I felt was best for those patients.”

“You did what you did because a certain other emergency-room doctor has been putting pressure on you.”

“That’s not true.”

“Now, just listen to me. I thought when we spoke in my office last week that we had an understanding about what it means to work in this town.”

You
had an understanding
, Abby thought.

“We’re here to do what’s best for this community,” Oleander went on. “And trying to undermine the company that keeps us all afloat is not being a team player.
Besides, I promise you, Colstar is not responsible for any illnesses. I would have thought you were convinced of that by now.”

So, she thought, the Lyle Quinn dot was connected to the George Oleander dot. But, of course, Quinn had already gone out of his way to tell her he was on the board of trustees at the hospital.

“George,” she said, “I’m doing the best I can to be a good doctor to the people of this town. If that’s not being a team player, I’m sorry.”

“Abby, the bottom line is this: I don’t want any more cadmium levels being sent off on my patients without speaking to me first. What happens when these people get their bills or insurance statements, and they learn that a doctor on the hospital staff thinks they’ve been poisoned by Colstar?”

“Might
have been. I—”

“Please, Abby. I mean it. Back off.”

“Whatever you say, George. They’re your patients.”

“Good. Now, I’m on backup for medicine today.”

“I know.”

“Well, I’m calling from the car on my way to my wife’s cousin’s. I’ll be twenty minutes away from the hospital. Twenty-five at the most. My service has the number. Treat anything that’s not life-and-death. Write holding orders on anyone you want to admit. This is an anniversary party. I’m going to try to stick it out here until five or six. Thank you.”

He hung up without waiting for a reply.

“Mr. Team Player,” Abby muttered.

She washed her face to cool down. Josh or no Josh, if life at PRH was going to be like this, she would take her chances somewhere else. It was hard to believe that two months ago she had been sitting with friends at a café by the water in Sausalito, talking about what sort of wedding she and Josh might have.

She was drying off when the charge nurse, Mary Wilder, pounded on her door and opened it a crack.

“Abby, come quickly,” she called out. “We’ve got big trouble.”

Abby grabbed her clinic coat from the chair and raced out.

“There’s been a bad accident at Patience Country Club,” Mary said, clearly anxious, but doing a decent job of remaining composed. “Some guy crashed his car through a fence onto a tennis court. He hit three women and then hit a pole or something. Apparently the injuries are bad. One ambulance is already on the way in, two more are on the scene. That’s it for the town’s ambulances. Tom Webb, the paramedic, will be calling back in just a moment.”

Abby felt her heart respond to a jet of adrenaline. Instinctively, she checked her clinic coat pockets for her instruments and the two thick loose-leaf handbooks she had put together over the years crammed with treatment protocols, medication interactions, and other pearls of experience. Multiple trauma on a Sunday morning with a reduced crew and limited backup. Her fears about leaving the shelter of St. John’s for a remote ER were about to become reality.

They hurried across to the communications area where the radio and telephones were clustered, along with a telemetry EKG unit.

“Do you want me to start the disaster drill?” Mary asked.

The drill, which each shift practiced once a year, was a telephone pyramid that would mobilize almost the entire hospital staff—medical, nursing, technical, and administration—within ten or fifteen minutes. Over a hundred people. Disruption, confusion, expense. The protocol was an on-off switch. Go or no go. There was no such thing as partial disaster drill. Abby knew the choice was the first of dozens, maybe hundreds, of critical decisions she would have to make over the minutes ahead.

“Not until we have a little more information,” she
said. “Find out who’s in-house and get them down here, please. Also, get whatever nursing help you need for—how many did you say?”

“I think four.”

“For four patients. Notify X ray and lab and have them call in their backups now.”

Mary used the phone on the counter to begin making calls. At that moment the radio crackled on.

“This is Fire Rescue Three, paramedic Tom Webb reporting.”

Behind the man’s voice Abby could hear the wail of the siren.

“Go ahead, Rescue Three,” she said. “This is Dr. Dolan.”

“Dr. Dolan, we are en route to your facility, four minutes out, with two—repeat,
two
—priority-two patients, both female in their thirties. Both were struck by an automobile while playing tennis. One has an obvious compound fracture of the lower leg. The other has multiple lacerations and abrasions. Both are conscious and alert. Vital signs in both are stable at present.”

“Received, Rescue Three. How many other victims?”

“Two. Another woman and the man who was driving the car. They’re in bad shape. Both are going to be priority one. Two squads are on the scene.”

“Received. We’ll be waiting for you.”

She turned to Mary Wilder, who had just finished a call. The nurse’s expression was grim.

“There are only two doctors in the house. Dr. Levin is doing a C-section, Dr. Mehta is doing the anesthesia.”

Abby threw the switch.

“Start the disaster drill,” she said. “Set up the two patients coming in now out here in the bays. Save the trauma room and major medical for the other two.”

Almost instantly the ER began to fill with nurses and technicians. But no physicians. Two crash carts were already in place. A third was brought down from one of the floors. Mary Wilder and the nursing supervisor
for the hospital quickly formed teams to work on each of the victims. Admitting clerks readied their clipboards. The blood-bank technician checked her stock and notified regional blood-supply centers to stand by. The X-ray tech moved the portable unit into position. The phlebotomist prepared his blood-drawing equipment and moved to a spot out of the way. Suddenly, eerily, for one frozen moment, the ER was completely silent, waiting. Then, from some distance, wailing sirens could be heard.

“Okay, everyone,” Abby said, sipping water to dampen the desert in her mouth, “let’s all keep cool and do what we know how to do.”

She gloved and hurried out to the ambulance bay just as a police cruiser and the ambulance sped in. The first victim, moaning piteously, had her right leg bundled in a bulky splint. Blood had already begun soaking through the gauze. Abby scanned her quickly—IV in and running wide, cervical collar on. Her face and tennis dress were blood-smeared and dirty with the red clay from the court. There was a nasty abrasion on her left shoulder. Abby glanced at the second woman and decided to follow this one in. One of the nurses was already cutting away her clothes.

“Rebecca Mason,” the EMT said. “Thirty-four. The only things we found are what you can see.” He lowered his voice and added, “Her leg’s pretty bad.”

Abby stopped the litter, checked to ensure that the
dorsalis pedis
arterial pulse on the top of the woman’s foot and the posterior tibial pulse behind her ankle were palpable. Then she marked the location of each with a pen and motioned the team into bay three.

Her first job was a primary assessment—airway, breathing, circulation. The ABCs of trauma. Speaking softly to the woman, Abby reassured her as best she could while she systematically checked vital functions, critical pulses, then skull, chest, and abdomen. She
heard her own voice, calm and firm, but felt oddly detached, as if it were someone else issuing the orders.