Critical Judgment (1996) (3 page)

“Dr. Clarke, I’m sorry. Maybe we should talk about this later. They should be here to take Mr. Tracy up to the unit any moment.”

“No, that’s okay. Go ahead. Tell me what I missed.”

Abby saw the tiredness in the man’s eyes. Never had she been out in a community caring for a busy, demanding general medical practice. And, in fact, until a few weeks ago, she had never even been detached from the university-hospital umbilical cord. She felt as if a sluice gate had opened, and all her feelings of irritation and impatience toward Gordon Clarke had instantly washed out.

“Dr. Clarke,” she said, “I’m sorry.”

“That’s all right.” Now it was Clarke who seemed irritated and impatient. “Just tell me what you think is going on.”

“Okay. He looks like he might have Cushing’s.”

Clarke closed his eyes for a moment and then nodded and sighed. Abby was saddened by what she knew he was thinking.

“That’s a heck of a pickup to have made under fire like that, Dr. Dolan,” he said. “You certainly saved Bill Tracy’s life.” Wearily, he met the gazes of Tracy’s wife and daughter. “Sorry Edith, Donna. I should have paid more attention to those potassium levels. I’ll see you up in the coronary unit.”

Quickly, he turned and left. As he passed through the
door, Abby realized that George Oleander, the chief of medicine, had been standing there, taking in the whole scene. Oleander had been one of the staunchest supporters of her application to fill the ER vacancy at PRH.

He watched Gordon Clarke hurry away, then turned back to the room. His eyes met Abby’s.

“That was a great save, Abby,” he said, with much less emotion than the words warranted. “Perhaps when you have a few minutes, you could stop by my office.”

I
t was nearly three before a lull in the steady stream of patients allowed Abby to clear out the ER and call George Oleander. Besides Bill Tracy’s resuscitation, the day had brought two more new cases of adult-onset asthma and one more of a skin condition that might have been hives, but really didn’t look like any hives Abby had seen before. The asthma cases raised to five the number she had treated in just over two weeks. Most of them had responded reasonably well to standard therapy and had been referred back to their own physicians. One had required hospitalization in the ICU.

Asthma beginning in adulthood was fairly unusual. Five cases in six months would have been more like it. Abby’s history taking had gotten more and more detailed, but so far no pattern had emerged. And no one on the medical staff seemed concerned or even interested.
Allergy Valley
was the way Oleander had referred to the area.
Pollen Central
.

The skin condition—raised, hard red welts that burned more than itched—was the second such case Abby had seen since starting at PRH. Dermatology was never her strongest suit, but at St. John’s it didn’t have to be. There was a derm clinic available during business
hours, and derm coverage twenty-four hours a day for anything beyond the mundane. The welts looked to her more like vasculitis, an inflammation of the small blood vessels in the skin, than like hives. But, in truth, they really didn’t look precisely like either. At their private doctors’ request Abby put both patients on oral cortisone and antihistamines, probably the best initial treatment for any inflammatory or allergic condition.

After Bill Tracy had been taken to the coronary unit, Abby had some fences to mend. She began with an apology to Tom Webb, the young paramedic. The tension of the moment had caused her to be more brusque than she had intended, she explained. He was damn good at what he did, and his skill in the other emergencies they had shared matched the best she had known in the city. The young man claimed he understood, but his expression made it clear he was still smarting.

Soon after, Abby sought out the nurse she had snapped at, Mary Wilder, and made amends to her for not explaining the rationale for IV potassium before ordering her to administer it. Wilder, ten years or so older than Abby, had been at PRH since well before the place was rebuilt a decade ago. The nurse was genuinely embarrassed by her hesitation in following Abby’s emergency orders and told Abby how much it meant to her and the other nurses to have a doctor of her caliber working in Patience. The two women shook hands warmly, and Abby returned to her patients with the sense that she had made her first genuine ally in the ER.

Gordon Clarke was the lone remaining ego casualty of the code ninety-nine. But righting things with him could wait until after her shift was over, and after her meeting with the chief of medicine.

George Oleander had an office in the Medical Arts Building, connected to the hospital by a covered passageway over the main driveway. The hospital itself, a three-story jewel of plate glass, brick, and cedar, was set
in a meadow at the easternmost tip of the valley, right at the base of the foothills. Whether the mountains beyond those rugged hills were the southern Cascades or the northern Sierras seemed to depend on whom you asked. To the west of the hospital sprawled Patience, a boom town during the gold rush, a mining town for many years after that, and then, from what Abby had been told, nearly a ghost town. Hikers and other outdoors lovers had always used the place as a jumping-off point and might have kept Patience alive. But it was the arrival of Colstar International, twenty-five years before, that had really turned things around.

As she passed through the glass-enclosed walkway to the Medical Arts Building, Abby gazed at the huge gray concrete factory, set atop a plateau a quarter of a mile from the hospital and several hundred feet up. The largest producer of portable power sources in the world, the Colstar brochures proclaimed; they made lithium batteries, lead acid batteries, alkaline batteries, solar batteries, rechargeables. Having been inside the factory once to see Josh’s department and office, Abby saw no reason to dispute the claim.

The Medical Arts Building, clearly designed by the same architects responsible for the hospital, featured two dozen office suites with balconies facing the mountains or the town. George Oleander’s second-floor office overlooked the flowering meadow, dotted with trees, that stretched out to the base of the Colstar cliff. It was a beautiful, pastoral view as long as one didn’t look up. In addition to the usual array of diplomas, postgraduate certificates, and testimonials, there were pictures of Oleander with two governors of California, and another with longtime California Senator Mark Corman, a possible Republican nominee for President.

The medical chief greeted her warmly. He was fifty or so, with graying temples and the soft, broad-shouldered physique of an out-of-shape athlete. The
redness in his cheeks and nose suggested to Abby that he might be a drinker. He motioned her to the chair across his desk, where she had sat for two interviews before being hired.

“So,” he said, “that was quite a performance.”

“I hope you’re talking about the code.”

“Of course I am. Abby, there’s absolutely no need to be defensive. You’ve been a wonderful addition to this hospital.”

“Thank you.”

No comment seemed necessary. Abby knew she hadn’t been summoned to be told what a bang-up job she was doing.

“The nurses have been very pleased with the last three ER choices we’ve made—Lew Alvarez, you, and, of course, poor Dave Brooks.”

This time Abby nodded her appreciation, not bothering to comment on the obvious—that if Dave Brooks hadn’t died in a rock-climbing accident, her own appointment would not have been necessary. The other four ER docs were husband-and-wife Chris and Jill Anderson, Ted Bogarsky, who commuted in from someplace twenty or thirty miles to the west, and Len McCabe, an aging GP. During her orientation week Abby had been assigned to double-cover with each of them and with Alvarez. None of the five was a liability in the ER, although skittish, insecure Jill Anderson was close. But only Lew Alvarez showed a genuine flair for the work.

“The medical staff likes you, too,” Oleander continued.

“I have my doubts about that.”

“They do. I can tell. It’s just that … Abby, we’re small town here. Until we know someone, and know them well, the
way
they say things is as important as what they have to say. You’re big city—and big city university hospital to boot. That makes you threatening to
some people right from the get-go. One person told me that you seem tense and short with people. He said that a lot of the medical staff were … I don’t know … intimidated by you. I didn’t really understand why anyone would feel that way until this morning.”

“Dr. Clarke.”

“Gordon’s an extremely nice man, and devoted to his patients. He’s been here for over twenty years, almost as long as I have.”

“And I made him feel like a jerk.”

“I don’t think there’re many physicians who would have plucked Cushing’s syndrome out of the air the way you did.”

Abby stopped herself from pointing out that Clarke really should have paid attention to the two low potassium levels he’d gotten on Bill Tracy in his office. Oleander was right. She hadn’t been relaxed about her job since the day she had accepted it. For the umpteenth time since then she wondered if she had made a mistake. As far as she knew, no one at St. John’s, not even the good old boys who always had trouble accepting women docs in positions of authority, had ever felt anything but pleased at having her around. Now, just by being herself, she was a threat.

She tried reminding herself that being with Josh, planning their life together, was worth the decision she had made. But even that thought didn’t fit as comfortably as it once had.

“The Cushing’s was a lucky shot,” she said. “Assuming it’s even confirmed by the lab. A flat-out lucky guess. George, you’re right. I have been too tense here.”

“About what?”

“I don’t know. Maybe just the newness of everything.”

“I understand. Are things okay at home?”

“What do you mean?”

“You told me in our first interview that you wanted
to move here because your fiancé had relocated to work for Colstar.”

Actually, he’s not technically my fiancé. We haven’t really set a date
. She could have said it but didn’t.
And yes, the tension has everything to do with how things are at home
.

“Things are fine with Josh,” she said. “Thanks for asking. It’s me. You know, you may not believe this, but I’ve been scared stiff about coming here since the moment you called to tell me I had the job.”

“I understand. Patience is a far cry from Union Street and Golden Gate Park.”

“Believe it or not, it wasn’t the town. It was the hospital. I went from med school to training to a staff ER position at St. John’s. Except for a little moonlighting I’ve always had the protective cocoon of knowing specialty help was never more than a few floors away. I have this overwhelming admiration for docs in remote ERs who have to do the whole thing themselves. Everything. The pediatric trauma and the adult codes. The stabilizing orthopedics and respiratory failure. Even the emergency neurosurgery.”

“We’re not
that
remote, Abby. We have a helipad. San Francisco’s just an hour or so from here by chopper.”

“Weather permitting. Don’t misunderstand me, George. I love the feeling that no matter what happens, no matter what’s thrown at me, I’ll know what to do about it. It’s just that for the last ten years I’ve always been able to call for help.”

“We’ve got a hell of a staff for a hospital this size.”

“I know. Hey, I don’t mean to sound like a wimp. And I understand that the most any of us can ever do is our best. But I still don’t like making errors.”

“None of us does.”

“For the four weeks between hearing from you that I got this job and actually starting it, I spent almost every free moment studying.”

“Judging from your résumé and letters of recommendation, I would never have guessed that.”

“Well, it’s true. And I think if I’ve seemed tense to people, that’s the reason. A community hospital is uncharted waters for me. I don’t want to make a mistake. Reputations in hospitals, especially negative ones, are created very quickly and recast very slowly.”

“That’s precisely why I called you in today. I want your reputation here to reflect the fine physician you are. Nothing else.”

Abby’s page summoned her to the ER at almost the instant Oleander’s receptionist knocked and peered in around the door.

“That was the ER, Dr. Dolan,” she said. “Just three patients waiting. Nothing critical.”

“Thank you.”

“I’m sorry I missed you when you arrived. I was over at the lab. I wanted to thank you for doing such a good job on my nephew Brendan’s cut chin. He’s only five. I’m sure you don’t remember him, but—”

“As a matter of fact, I remember him very well. We redheads pay attention to one another.”

“My sister said you kept whispering to him while you were getting ready to sew him up.”

Abby smiled. “I was just reminding him that he was in charge, and that I would stop anytime he told me to. When I was a kid, I used to hate the feeling of losing control of any situation, especially one in the hospital or dentist’s office. In fact, I still feel that way. I always try to make sure kids know they still have power.”

“Well, my sister said you were just great with him. Do you have children?”

“No … no, my fiancé and I hope to have some before too much longer, though.”

“Well, I hope you do.”

The woman smiled, pulled her head back, and closed the door.

“I rest my case,” Oleander said. “Everyone in Patience
is connected in
some
way or other with everyone else. And no one is more important than the doctors. You’ve already made a great impression on the town. You just have to practice being a little gentler on the staff.”

“Consider it done.”

“Thank you.”

Abby stood and shook Oleander’s hand.

“I’m curious,” she said. “Which doctor was it who said I seemed tense and short with people?”

Oleander debated responding.

“To tell you the truth,” he said finally, “I think Dr. Alvarez said something to me in passing. Given that it was him, I probably shouldn’t have even bothered mentioning it. Alvarez is an excellent physician, but if you’ll excuse me for saying so, he’s not much of a team player. He seems to have an opinion about pretty nearly everything and everybody. And he isn’t the least bit shy about spreading it around. Sort of like fertilizer.”