Critical Judgment (1996) (4 page)

Oleander enjoyed a laugh at his own humor. Abby smiled politely.

Lew Alvarez. She supposed she should have known. Alvarez was clearly the top dog in the ER—at least until her arrival on the scene. But he was almost too self-assured. That and his irrefutable good looks had been something of a turnoff to her. It was hard to imagine his perceiving her as a threat, but she knew that was the sort of thing one never could tell about a person.

“Thank you for telling me,” she said. “I’ll see what I can do about changing his opinion of me.”

“Suit yourself. Personally, though, I don’t think Lew Alvarez’s opinions matter all that much.”

Abby wondered why the medical chief was so skeptical of Lew Alvarez despite the nurses’ high regard for him. But this wasn’t the time to get into it. She thanked him for his candor and left the office.

Heading back to the emergency room, she admitted
to herself, perhaps for the first time, that of all those on the medical or ER staff, it was Alvarez she had most wanted to impress.

So far it appeared she hadn’t done a very good job of it.

B
efore returning to the ER Abby stopped by the ICU. Bill Tracy was extubated and propped up at a forty-five-degree angle, taking sips of water through a straw. His wife hovered over him from one side of the bed, his daughter, Donna, from the other. All things considered, Abby thought, he was looking damn good.

She stayed by the nurses’ station long enough to take in the scene, then left without going into the room. Mindful of the situation with Gordon Clarke, she was purposely shying away from contact with Tracy and his family. Besides, she realized how easily things could have gone the other way. This was a time for reflection and gratitude, not celebration—and certainly not smugness.

It was almost five-thirty when she reentered the ER. Two and a half hours until her relief showed up. Ironically, it would be Lew Alvarez. She’d have a chance to practice her new, nonthreatening manner.

There were now four patients to be seen—one in the waiting room, one in X ray, and two on stretchers. None of them seemed too complicated at first glance, but she could recall dozens of examples, secondhand and personal, of the folly of relying on your first glance. She rubbed at the gritty fatigue in her eyes and wished she
was home. She wanted to call and check in with Josh, but it was doubtful he would be back from work yet. The ER was just a patient or two from becoming backed up, and the nurses had already begun ordering tests on the two who had been there longest. Abby decided to make sure things were going in the right direction before she called home.

The evening charge nurse, Bud Perlow, met her at the chart rack. He was an imposing six foot four, but Abby had seen him use his puttylike face to put kids at ease. At five eight she had to step back several paces to make eye contact with him comfortably. She encouraged all the nurses to call her by her first name, but Perlow was one of the few who insisted on Doctor.

“Dr. Dolan, rescue is on its way in with Old Man Ives,” he said. “He’s been beaten up. Primarily facial lacerations.”

“I don’t know any Old Man Ives.”

“Oh, sorry. I forgot you’re new. Just about everyone in Patience knows him. He’s a hermit. Very weird—retarded, I’ve heard. Lives in the woods. Someone told me he actually lives in a cave. He comes into town every few weeks to sell his carvings and pick up supplies. Usually people leave him alone, but apparently this time someone didn’t.”

Abby took two charts from the rack.

“I’d better get a move on, then.”

“It may not be a problem,” Perlow said. “Dr. Bartholomew’s on backup for surgery, and he’s in-house. I just saw him.”

“Great.”

The word came out more sarcastic than she had intended. Martin Bartholomew, one of four general surgeons on the staff, insisted on suturing every laceration that came in while he was on backup. Although Abby had yet to have a run-in with him, she had been warned by the other ER docs that it was only a matter of time. Bartholomew had an ego as bloated as his waistline, and
unique requirements for even the most mundane procedures. It was sport for him to chastise a nurse in front of one of his carriage-trade patients for forgetting his special clamps or for opening a 6-0 instead of a 7-0 packet of suture.

“Shall I call him now?”

“Better let me at least check over Mr. Ives first.”

Through the waiting room Abby could see another patient enter, this one a middle-aged woman, pale but ambulatory, supported by her husband. Probably a GI bug, she guessed. It was definitely time to get in gear.

The patient in X ray had a straightforward, nondisplaced wrist fracture. Plaster splint, a few Tylenol number threes, and an orthopedic referral. But the two patients on stretchers were both enigmas. Neither was a true emergency, but their insurance probably didn’t charge them a penalty for using the ER instead of contacting their primary doctor. One complained of fatigue and a low-grade cough, the other, a flamboyant fifty-year-old redhead, of chronic severe itching with no noticeable skin rash. Physical exams on both were negative, as was the chest X ray Perlow had obtained on the cougher. Abby ordered some additional laboratory studies but suspected that they, too, would be unrevealing. Two more in what was beginning to feel like a series of ill-defined or unusual conditions.

Was it her imagination, or had she been starting more and more of her discussions with patients by saying something like, “At this point I don’t really know what’s wrong with you, but …”? The challenge with cases like these, maybe the most difficult in ER medicine, was to be certain that no one was discharged feeling that his symptoms were being taken lightly. Patients like that were lawsuits waiting to happen. Abby was constantly reminding herself that although a particular problem might not have been the worst thing she had seen that day, it was certainly the worst thing the
patient
had had.

While the two remaining patients from the waiting room were being evaluated by the nurses, Abby closed herself in the small doctor’s office and called home, expecting to get the answering machine.

“Hello?”

Not only was Josh home, but it sounded as if she’d awakened him. Lately it had been more and more like that. For the two years they had dated, before he’d moved to Patience, sleep had been something of an enemy to Josh. Even during his months of unemployment he had stayed upbeat and energetic. Maybe those ten months had taken more of a toll than she’d realized, though. Or perhaps the expectations and pressures of his job at Colstar had been more than
he
had bargained for.

Over the five weeks they had been together in Patience, and even before she had moved up to join him, Josh had been irritable, distracted, easily fatigued, and bothered by headaches. A checkup with lab tests at the Colstar employees’ clinic, done at Abby’s insistence, had turned up nothing. But the disturbing changes in him had persisted. Recently, she had begun to wonder if she had wanted so badly for their relationship to work that she had never allowed herself to see Josh’s darker side.

“Hi, honey,” she said. “Are you okay?”

“What’s that supposed to mean?”

“Nothing. You just sounded tired.”

“I’m sorry. I was on the couch. I … I guess I must have fallen asleep.”

On the couch … fallen asleep
 … The Josh Wyler she had fallen in love with probably hadn’t taken a nap since he was two months old.

“Well, you left for work at five-thirty this morning,” she said. “Maybe you should start a little later.”

“Do you want to do my job, too? Is that it?”

Abby refused to allow him to push any of her buttons, although lately he’d become something of a virtuoso at it. She wanted to ask him about the headaches
he’d been having. But that might well have pushed one of
his
buttons, and she simply had no time or desire for a battle.

“I’ll be home by eight-thirty,” she said instead. “How about I bring home some Chinese food and rent a movie?”

“Sure. That’d be great.”

There was no enthusiasm in his voice. The problem
had
to be his job. For the first few months after he’d started as director of new product development at Colstar, the job had been the best thing that had ever happened to him. Then, suddenly, there were constant deadlines—new products that always seemed to be at a make-or-break stage. He had never been particularly vulnerable to pressure at work. Now he seemed overwhelmed, disorganized.

Meanwhile Abby’s decision to apply for the sudden opening in the ER at Patience Regional Hospital seemed only to have added to Josh’s stress. Since her move up to Patience, there had been almost constant tension between them. Perhaps he had never expected her actually to give up the job she loved out of deference to their relationship. Maybe, over the months they’d been apart, he had simply discovered he liked being on his own. Or maybe, she sometimes allowed herself to think, he had met someone else.

The doors to the ambulance bay glided open, and the rescue squad wheeled in a stretcher. The man on it had his face swathed with blood-soaked gauze. Protruding from beneath the gauze, over the cervical collar, was a full, gnarled gray-black beard, matted with drying blood. Old Man Ives.

“Look, Josh, I gotta go,” she said. “I’ll tell you what. Count on me to provide dinner and X-rated entertainment. If you want to watch the movie afterward, we can do that, too.”

“I’ll be here.”

Abby started to tell him that she loved him. Instead what came out was, “Great, see you later.”

She set the receiver down and headed out to evaluate her new patient, thinking that she shouldn’t have called home. The last thing an ER physician needed at work was to be distracted. The job was hard enough, the traps were everywhere. From now until her shift ended she would have to be especially vigilant.

The PRH emergency room had a row of five treatment bays separated by curtains, and five individually numbered rooms, reserved for minor surgery and orthopedics, special procedures, major medical, pediatrics, and codes. Abby felt some relief at seeing Bud Perlow direct the rescue squad to wheel Mr. Ives into room one, where most of the routine suturing was done. She just wasn’t up for anything major.

She paused to check on some of the lab results on the two enigmas. To no surprise, they were all normal.

“Ouch! Hey, easy. You just took half my hair off on that tape!”

Perlow met Abby beside the door to room one. From behind him she could hear their new patient jawing at the rescue squad.

“Some hikers found him facedown on a trail. Apparently two men followed him out of town, started yelling at him to stay away from Patience, and then beat him unconscious with their fists.”

“I guess different isn’t one of the best things to be around here.”

“Pardon?”

“Oh, nothing. How does he look?”

“He’s awake and alert, in case you couldn’t tell. Deep lacs on both cheeks, through one brow, and across his chin.”

“Alcohol?”

“I couldn’t smell any. But, then, Ives is a few months short of a shower.”

“I understand.”

Abby liked that she heard nothing judgmental in the nurse’s voice. It was human for any physician or nurse to be offended by a person’s smell, or obesity, or age, or even illness. Everyone had an upbringing and a history to deal with. Everyone had sensibilities. But it was not acceptable to her when medical personnel withheld a full measure of care because of their prejudices.

She took the chart from Bud Perlow and was reading it as she entered the room. Old Man Ives was Samuel Ives. His address was given simply as North Hills, Patience. His age was fifty-one. She wondered if, in just sixteen years, the people of Patience would be calling her Old Lady Dolan.

She put on a paper gown and rubber gloves and began her assessment before even reaching the bedside. The man’s face had taken a pounding, but it was not as fearsome as she had imagined.

“Mr. Ives, I’m Dr. Dolan. How’re you doing?”

“They stole my money.”

Abby glanced over at the paramedic, who shook his head.

“Mr. Ives,” he said, with the overemphatic voice that most health-care workers seemed to use toward most patients, “I’ve got your wallet right here.” He slipped a plastic bag under Ives’s hand. “There’s twenty-one dollars in it. Your book and what’s left of your carvings are in the bag beneath your stretcher. They must have taken your groceries. We didn’t see them anyplace.” He turned to Abby. “The police came up to the trail with us. They think they know who did this, but Ives doesn’t want to get involved. Whoever it was stomped on his carvings. There’s not much left of them.”

“Are you hurting anyplace except your face, sir?” Abby asked.

Ives shook his head.

Abby briefly checked his ribs, heart, and abdomen. There was no tenderness.

“Any problem with your vision?”

“Nope.”

“Are you seeing double? Two of anything?”

“I know what double means. No.”

“Mr. Ives, I think we should get some X rays of your face and neck.”

“No. They’re fine. I’ve had broken bones. I know what they feel like. I don’t have any broken bones and I don’t want any radiation.”

Radiation
. Not the word she would have expected from this man. She peered down at him, trying to look beyond the oil-stained clothes and the gashes and the beard, trying to see through her own prejudices. Samuel Ives’s light-blue eyes were bright and piercing.
So what’s your story?
she wondered.

She checked his eyes and cheekbones to be sure there were no gross signs of a fracture. Then she loosened his cervical collar and felt along his spine. No tenderness there, either.

“Okay,” she said, “no X rays. I’ll be back to examine you more thoroughly, then we’ll get your face fixed.”

Ives looked directly at her for the first time, as if surprised at the ease with which she had given in.

“Thanks, Doc,” he said.

“Dr. Dolan,” Bud Perlow called out from the doorway. “Could I see you please?”