Heart Failure (17 page)

Adam wondered what was coming next. Was Johnson about to back out? There was no way he could have any idea what Adam had in mind, was there?

“I think you’re a good man. I doubt that you’ll be using this to hold up a convenience store.” Johnson took another sip of coffee. “Whatever trouble makes you need this, I hope it helps.” He shoved the shoebox toward Adam. “Three hundred cash, including a box of 9 millimeter ammo.”

Adam unfolded three hundred dollar bills from his diminishing roll and laid them on the table. He rose and picked up the shoebox. “Thanks.”

“As a good citizen, I should remind you that you’re supposed to take the class and get a carry permit for that pistol.” Johnson unfolded himself from the chair like a carpenter’s rule. He stuck out his hand. “Good luck, son.”

Adam started back toward his car. He’d need all the luck he could get.

Carrie let the noontime buzz of the café wash over her, providing an auditory backdrop for her deep thoughts. Her Coke sat forgotten, its bubbles rising slowly to the surface. The sight and smell of her Reuben sandwich failed to tempt her. She idly munched on a potato chip and replayed her morning in church.

As she expected, there’d been questions about Adam. After a couple of them she had the new answer down pat:
He had to leave town in a hurry because of a family emergency.
That’s why no one knew any details. He called me this morning. Things are okay now, and he’ll be back tomorrow
.

The sermon? Not the best she’d ever heard, but then again, how much attention had she paid? Her mind had been on Adam. She could hardly wait to see him. She was anxious to hear about his trip. The electronic strains of Beethoven’s “Fifth Symphony” cut through the chatter and clatter around her. Carrie picked up her cell and saw that the caller was Lila.

“Dr. Markham, I’m so glad you picked up.” Lila’s voice was breathless, and Carrie had the impression the woman was on the verge of tears. This was a far cry from the breezy, self-assured nurse with whom she worked every day.

“Lila, what’s wrong?”

“It’s my mother. She’s in the ER, and they’ve called Dr. Avery to see her. But I really wish you’d come.”

Carrie stared at her plate as though the sandwich and chips had just materialized there, surprising her with their presence. She raised a hand and beckoned a passing waitress. Carrie handed over her VISA card, pointed to the plate, and mouthed, “To-go box.” There was no way she could fail to respond to Lila’s plea. “I’ll have them cancel the call to Dr. Avery. What’s the problem? I need to tell the ER doctor what I want done while I’m in transit.”

The relief in Lila’s voice was obvious. “Mom complained of a severe headache this morning. I keep a blood pressure cuff at home to check my own pressure, so I decided to take hers. ”Her voice broke and the panic returned. “It was two twenty over one fifteen!”

“That’s high, but we can get it down. What has the ER doctor done so far?”

Lila’s deep breath whistled in Carrie’s ear. “They drew some blood, ran an EKG, which I haven’t seen, and gave her IV labetalol.”

“Beta-blocker. Good choice,” Carrie said. The waitress appeared with the check, plus a to-go box and a Styrofoam cup for Carrie’s drink. She nodded her thanks. “That’s pretty standard. Is her pressure coming down?”

“Yes. Of course, I realize they want it to come down slowly. It’s not that. It’s what the ER doctor wants to do now.”

“Go on.” Carrie snugged the cell phone between her ear and shoulder while she added a tip and signed the check.

“He wants to admit her and start a workup for pheochromocytoma.”

Pheochromocytoma, a benign tumor of the adrenal gland, was certainly one of the causes to be considered in cases of chronic hypertension, but its incidence was estimated at about one per one thousand cases. And this wasn’t chronic. The last time Carrie examined Lila’s mother, Mrs. James had mild elevation of her blood pressure—not enough to merit medication, but sufficient to get her a lecture on the need for weight loss. The reported blood pressure now was certainly high, but it was too soon to jump to a workup for pheochromocytoma.

A phrase Carrie had first learned in medical school popped into her mind. She smiled the first time she heard it, but the wisdom behind the words was soon evident to her. Now she frequently repeated the words to medical students when discussing a differential diagnosis:
When you hear hoof beats, think horses, not zebras
. She picked up her food. “You’re right. I think that’s a bit radical. I’ll call the ER right now and be there in fifteen minutes.”

Carrie disconnected the call, then pushed the speed-dial button for the ER as she strode out of the café to her car, her lunch in hand. When the nurse answered, she said, “This is Dr. Markham. My nurse, Lila, is there with her mother, Mrs. James. Please call Dr. Avery and tell him not to come out. She’s my patient and I’m on my way to take care of the situation. And let the ER doctor know too.” She’d give him the horses and zebras talk later—in private.

Carrie pulled away from her parking spot, looked in her rearview mirror, and went cold all over. A dark blue Ford Crown Victoria had dropped into traffic right behind her. Well, she didn’t have time to do the deke and dodge thing now. She headed for the hospital. Let them follow her. There should be enough people around to discourage an attack when she arrived, and maybe she could get one of the security guards to walk her to her car when she left. Right now she had to forget about her own safety and focus on Lila’s mother.

After she entered the ER, Carrie picked up Mrs. James’s chart at the nurse’s desk and did a bit of mental arithmetic. Almost an hour had elapsed since Jeff Clanton, the ER doctor, began treating Mrs. James. In that time the woman had received an initial IV dose of a beta-blocker, following which an IV drip delivered more of the drug in a controlled fashion.

The treatment seemed to be working. Carrie headed for the curtained cubicle where Lila’s mother lay and saw Jeff Clanton on a course designed to intercept her. Since he was the ER doctor on duty, that might explain some of this. Jeff
was a recent graduate of one of the lesser-known medical schools in the south. He’d applied to three family practice residencies but hadn’t been accepted at any of them. That wasn’t totally uncommon—competition was pretty fierce at some institutions. One told Jeff they’d take him next year, so he was working here both to make a living and get experience until that slot opened up. To this point, Carrie hadn’t had any problems with his performance. Jeff seemed anxious to profit from his time in the ER, and this seemed like a chance for her to do a little mentoring.

“Blood pressure’s coming down nicely,” Carrie said to Jeff as the two doctors stood at Mrs. James’s bedside. “What do you think caused the hypertension?”

The ER doctor looked embarrassed. He inclined his head toward the curtains surrounding the ER cubicle. “Uh, think we should step outside?”

“Not at all,” Carrie said. “Mrs. James is a retired LVN, and her daughter, Lila, is my clinic nurse. They’re used to hearing doctors discuss cases, and I think they need to hear this. Besides, I have a question I want to ask our patient, and I think her answer may surprise you.”

“Okay.” He cleared his throat. “She says her blood pressure’s always been high, but she wasn’t on any medication. I took that to mean that this was a sudden spike. To me, that suggested an adrenal tumor, so I asked Dr. Avery—” He paused and gave her an apologetic look. “I would have called you, but he’s on call—Anyway, I suggested a pheochromocytoma workup.”

Carrie clamped down on her back teeth.
Be cool. He’s just out of med school
. “What’s the first thing you think of when you encounter a patient with a sudden rise in blood pressure?”

“Several things. Eclampsia, of course—but she’s not pregnant. Renal disease, but her BUN and creatinine came back normal. She drinks two cups of coffee a day, no energy drinks, no Cokes. And her only medication is a hormone preparation. That leaves something like an adrenal tumor suddenly becoming active. I know it’s unusual, but I think we should rule it out.”

Carrie nodded. Jeff was right so far, but there was another possibility, one Carrie herself might not have considered had she not encountered it a year or so before. She turned back to her patient. “Mrs. James, what medicines do you take?”

The woman thought about that for a few seconds. “Just my hormone pill, like he said.”

“What other pills—not prescriptions, just pills—what others do you take? What did you take today?”

“Well, you told me I had to lose weight, so I went to the health food store on Friday and got a bottle of weight loss pills.”

Carrie glanced at Lila, and she saw her nurse’s expression change as the light dawned.

“And did you take one of those today?” Carrie asked.

“Actually, the first one didn’t seem to have much effect, so I took two yesterday. This morning I decided to try three. I mean, they’re natural, so I don’t see how they could be bad for me.” She turned to Lila. “I think they’re in my purse.”

Lila opened the satchel-like purse slung over her shoulder, rummaged for a minute, and extracted a white bottle with a purple and white label that read, “Bitter Orange.”

Understanding lit up the younger doctor’s face. “I should have asked about nonprescription drugs.”

“You don’t use the word ‘drugs.’ You don’t say ‘medication’ or ‘prescription.’ You ask if they’re taking any pills, whether
they got them from the doctor or bought them over the counter. You ask what they took today—this day, not regularly.”

He nodded. “I—”

“It’s okay,” Carrie said. “We’ll talk about it later. Right now, let’s titrate that blood pressure down to a safe level.”

Almost two hours later Carrie was ready to leave the hospital. She’d arranged to admit Mrs. James overnight for observation in order to taper the dose of the beta-blocker medication and observe for any heart damage from the episode. Dr. Clanton had learned a valuable lesson about horses and zebras. And Lila couldn’t thank Carrie enough for coming to the hospital when she wasn’t on call.

“No problem,” Carrie reassured her. And it wasn’t. Her time in the ER certainly had been more productive and more satisfying than a Sunday afternoon nap.

Carrie almost forgot the blue Ford that followed her to the hospital—almost, but not totally. She found a security guard in the Emergency Room waiting area and approached him. “Would you mind walking me to my car?”

It was a strange request, since it was broad daylight, but the guard either was used to such appeals or was unusually patient. In either case, he rose, giving her neither a puzzled look nor furrowed brow, and accompanied Carrie to her car, one hand on his holstered weapon, his head moving from side to side as though expecting trouble. She wasn’t sure if he really believed her or was putting on a show, but in either case she welcomed his presence.

At her car Carrie thanked the guard and prepared to climb in. But just before she slid behind the wheel, she scanned the parking lot and saw a tall man, wearing a Stetson, leaning
against the fender of a blue car three rows ahead of her. He was dressed in a suit and tie, and his manner was anything but threatening. He smiled and began walking toward her.

Carrie looked around. The security guard was almost back to his post. She was about to start running toward safety when she heard a soft voice with a definite drawl say, “Dr. Markham?”

The stranger wasn’t hurrying, but rather ambled along as though he had all the time in the world. She found herself rooted to the spot, wondering if a scream would get the guard’s attention in time.

The man tipped his hat. “There hasn’t been a good time to introduce myself,” he said. He reached into his pocket and showed her a leather wallet with a badge inside it. “Sam Westerman, U.S. Marshalls Service. I was asked to keep an eye on you while your . . . er, your friend is out of town.”

Carrie wasn’t sure how she felt—grateful that Adam was trying, in his own way, to keep her safe or angry that he hadn’t bothered to mention it to her. “Thank you. I appreciate it,” she said.

After Westerman touched the brim of his hat and ambled away, Carrie climbed into her car. As she pulled into her driveway, Carrie waved to the blue Ford behind her.
Thanks, Mr. Westerman. Thanks, Adam
. She decided she wasn’t angry. In a few hours she’d see Adam again. That was enough.