Oath of Office (4 page)

DeLand Regional, a few miles west of the town, was a level-two trauma center, which meant that orthopedics, neurosurgery, and plastics were covered, although not necessarily in house all the time. According to the news, John Meacham had survived a gunshot wound to the right temple. Under usual circumstances, patients with such an injury would have been transported by chopper to the nearest level-one facility, in this case, Eisenhower Memorial itself. Perhaps a neurosurgeon was available at DeLand, Lou speculated, and didn’t want to lose a juicy case. Or perhaps the weather was too chancy.

Poor goddamn Meacham.

What in the hell happened out there?

John Meacham was tightly wound, but not
this
tightly wound. In fact, he had a better-than-decent recovery program, and had mellowed considerably. Word was bound to get out that he had been attending Alcoholics Anonymous meetings for four years, and a few hundred alcoholics and drug addicts in need of the program would decide that they were better off going it on their own.

Any excuse in a storm.

Meacham was one of the first docs Lou had been assigned after he went to work part-time as the assistant to the director of Physician Wellness. A father of three, and a history buff, the internist was a lifelong Virginian, working in D.C. at the time. He played bluegrass on several instruments and could take his motorcycle apart and put it back together. The only two drawbacks in his life were his temper and alcohol. The day he exploded at one of his patients for continuing to smoke following a coronary, Meacham admitted to Lou that he had a ferocious hangover after drinking the night before. The result of his outburst was a report by his patient to the board, a six-month suspension, and a referral to the PWO.

Lou ordered an immediate psych evaluation and sent Meacham away for a month of rehab and anger management. As soon as he was discharged home, Lou signed him to a legally binding monitoring agreement—random urine testing twice weekly, regular psychological therapy, frequent face-to-face sessions with Lou, and involvement with AA.

What could go wrong?

Much to his chagrin and that of his dentist, Sid Moskowitz, Lou was a teeth clencher and grinder. Moskowitz had been pushing forever for some kind of mouth guard, but even in the ring, Lou could barely handle an appliance jamming up against his gag centers like two stalks of rubber celery. He could kick the grinding habit, he insisted, even as Moskowitz was totaling up the cost of the crowns he would soon be installing. He could kick the habit just as he had kicked the drugs.

But not today.

With the wipers slapping steadily, Lou turned into the crowded physician parking lot of DeLand Regional. Four cruisers, strobes flashing, were parked near the ER entrance. Twenty-five yards away was a phalanx of sound trucks. Lou estimated that the glass-and-redbrick three-story hospital had a capacity of somewhere between 150 and 200 beds. It had a decent reputation from what little he knew, although he had no firsthand experience with the place.

Before he made it to the elevator and up to the second-floor ICU, Lou’s credentials were checked three times. There were two uniformed cops—a woman and a man—posted outside the unit, and another man, a broad-shouldered African American in plainclothes, whom Lou guessed might regularly rehearse his air of authority in front of a mirror.

“No one’s allowed in there,” the man said, performing a heavy-lidded inspection of the new arrival.

“I’m a doctor.”

“So’s the guy in there who just killed seven people.”

“Nice comeback. How about if I said I was a close friend of his?”

“ID?”

Lou passed over his driver’s license and wallet-sized medical license. “Neither of these say I’m a close friend of his. I left that one at home.”

“I can be a wise-ass because I’m in charge,” the detective said. “You can’t, because you’re not. And the head nurse left word that no one is to be let in until she says so. They’re going after the bullet in your close friend’s head.”

“They’re what!”

Incredulous that they were going after the bullet in the ICU and not the operating room, Lou stared across at the man, who looked perfectly serious.
Not possible
, Lou was thinking. Even in the most ragtag level-two trauma center imaginable, no one would be fishing for a bullet while inside the ICU. Generally, what remained of the slug were fragments, and more often than not, the brain trauma caused by trying to remove them wasn’t worth the benefits. But no matter what, any procedure, whether an exploration or a decompression maneuver to reduce swelling, would be performed in the operating room.

“Going after the bullet,” Lou said. “Of course. Just like they do all the time in the movies. Usually, that’s when I snatch up my popcorn and leave.”

“Too gross?”

“Too absurd.”

The remark appeared to have sailed over the cop’s head. “What kind of doc are you, anyway?” he asked.

“Emergency. I work at Eisenhower Memorial in the city. Who’s going after the bullet?”

“I have no idea. I don’t live around here. I’m state police. We were called in to take over for the locals.”

Lou was about to grill the man for information when the glass doors to the unit glided apart and a trim, olive-complexioned woman in scrubs emerged. Tension was etched across her face. It took only a second for Lou to recognize her.

“Sara!”

Sara Turnbull and he went way back—almost to the beginning of Lou’s residency, when he was razor sharp, thrilled to be having his dreams come true, and enthusiastic as the Energizer Bunny—back to before his father’s financial implosion, and Lou’s subsequent moonlighting jobs, and the extra shifts, and the utter exhaustion; back to before the unstoppable downward spiral and the amphetamines, and the visits from the drug-enforcement people.

“God, am I glad to see you,” Turnbull said. “When they called from downstairs to say you were on the way up, I nearly jumped through the phone. They’re killing him in there, Lou. I don’t care what he’s done, it’s not our job to judge.”

CHAPTER 5

“Okay if I go in there, Officer?”

“Sorry to give you a hard time,” the cop said. “It looks like you have a boxer’s knuckle, there. I’m not used to seeing doctors with boxer’s knuckles.”

“I work in a really tough ER,” Lou replied.

Sara Turnbull was a crackerjack nurse—as smart and intuitive as she was compassionate. There was a time when Lou could have added
passionate
to her list of attributes, but those times were long past. The last he had heard from her was a get-well card forwarded to him in rehab.

“How long have you been working here?” Lou asked as they joined the crowd milling in the gleaming ICU.

“Just four months. My husband’s a nurse on med/surg. We have a one-year-old son. It’s not Eisenhower, but it’s a decent-enough place—at least it was. This is a mess, Lou. An absolute mess. I’m charge nurse today, and I can’t follow some of the things that are happening.”

“Like someone blindly jamming a hemostat into a patient’s brain, fishing for a bullet?”

“Exactly. That’s Dr. Prichap. As far as I know, he’s a decent-enough neurosurgeon, but I’ve never seen anyone do that.”

“It may be a while before you see anyone do it again,” Lou said. “What else?”

“Dr. Meacham is going downhill fast, but no one seems all that alarmed. Do you know him?”

“For a few years. We’ve actually gotten to know one another pretty well. This came right out of the blue. I can’t believe he did it.”

“He’s over there in three. Dr. Schwartz, the intensivist, has been in and out, but mostly it’s been Dr. Prichap. It looks as if things have quieted down now. Prichap may have given up hunting for the bullet.”

“I hope so,” Lou said, almost to himself.

Lou followed Sara into the cubicle, which was crowded to near overflowing with nurses, radiology, lab, and respiratory techs, what appeared to be a resident, and a short, copper-skinned man—probably from India.
ANTHAR S. PRICHAP, M.D.
was stitched in blue over the breast pocket of his lab coat. Although he wore scrubs beneath his white coat, it appeared that he had performed surgery just as he was. Next to Prichap was a tray with bloody sponges and instruments piled on it.

No bullet.

On the bed, barely visible in the crowd, was John Meacham. His trachea had been intubated through his mouth, and he was being ventilated mechanically by a state-of-the-art machine that occupied most of the space the crush of bodies did not. A tall man—six feet or so—Meacham looked lost, almost diminutive. He appeared to be unconscious. His eyes were taped shut, and his head had been shaved on the right side. The bullet hole, just above his right ear, seemed to have been widened. On the wall view-box were anterior–posterior and lateral skull films showing a deeply embedded slug, fragmented into one small and two larger pieces, none of which were easily accessible to the entrance wound itself.

Dr. Schwartz, the hospital-employed intensivist, was apparently off with other patients. Why hang around for a plain old everyday gunshot wound to the head?

Lou introduced himself to Prichap, and received an uninterested nod in return. No handshake. Then, without a word, the neurosurgeon drifted into the background as Lou conducted a quick visual scan of Meacham. What he saw immediately disturbed him. There were two intravenous lines—one inserted in the elbow crux of Meacham’s left arm, and the other at the wrist of the right. The line at the elbow was barely running, despite a blood pressure reading on the monitor screen that demanded fluids and pressor medications—eighty over forty. Surrounding the spot where the catheter had been inserted was a large swelling. The line was infiltrated, and rather than pouring life-supporting fluid into the circulatory system, it was pooling fluid in the tissues.

Careless, dangerous medicine.

“Sara, that needs to be replaced,” he said, pointedly ignoring Prichap, who, at that moment, was looking rather pleased with himself for whatever reason.

The Sara Turnbull he remembered would never have allowed a critically traumatized patient to have only one working IV. Perhaps in the chaos, she simply had not noticed. In seconds, she was taking down the dressing and preparing to replace the IV line—this time at the wrist.

Lou glanced up again at the perilously low blood pressure reading, which had dropped from a systolic of eighty to seventy-four. Unless the cause could be identified and reversed, John Meacham was heading out. Quickly, Lou began mentally ticking through the possibilities. It took only a few seconds to connect with the right one.

Stunned at what he was seeing, Lou worked his stethoscope into place and listened to Meacham’s chest. There were no breath sounds on the right side. The exam was not really necessary. All the information he needed was visible in the distension of the jugular veins along the sides of the man’s neck, the slight bowing of the trachea toward the left, the persistently low oxygen saturation, and the asymmetrical hyperexpansion of the right chest.

A tension pneumothorax—collapse of the right lung due to a tear, probably caused by excess pressure from the ventilator. Air was being forced by the vent through the ruptured lung and into the chest cavity. The midline structures including the heart, esophagus, aorta, and other great vessels were being pushed to the left. The absence of breath sounds on the right merely confirmed the diagnosis.

Lou noted that the vent pressure was dangerously high and turned it down. From beside the machine, the respiratory tech—a tall, pencil-necked man in his late twenties—stood smiling at him blandly.

Did you do this on purpose?
Lou wanted to shout.
Did you?

“Everyone, please, listen to me,” he called out, louder than he’d intended. The commotion immediately stopped. “I’m Dr. Lou Welcome from the ER at Eisenhower Memorial. This man has a rapidly expanding tension pneumothorax. We need to dart his chest immediately to get the air out of there. Then we’ll get a chest tube in. I need an IV angiocath in a number sixteen or fourteen needle. Quickly, please.”

Missing from the emergency, except in himself, was any sense of tension and urgency. Lou wondered if anyone in the room really cared whether John Meacham made it or not. It would not be hard to understand if they didn’t, even though, as Sara had said, it should never be a caregiver’s role to pass judgment on any patient.

This was as bad as it could get.… Poor bastard.… Poor victims.

What in the hell happened?

A large-bore needle with a plastic catheter running through it was brought on an instrument tray, along with latex gloves, a large syringe, surgical sponges, some surgical snaps, and several culture tubes.

Blood pressure, seventy over thirty. Oxygen saturation, 60 percent. Color worsening.

Moving rapidly, Lou gloved and swabbed some Betadine antiseptic below Meacham’s collarbone on the right side. Then he set the plastic catheter aside and attached the needle to a 20 cc syringe. His movements were careful and considered, but almost automatic, like a boxer throwing a right-left-right combination.

To Lou’s left, behind the crowd, he could see the neurosurgeon, Prichap, gazing almost placidly out the glass wall of the cubicle. No apparent concern, no offer to help out.

The needle thrust was where the right second rib space was intersected by an imaginary line between the middle of the collarbone and the nipple. Gripping the syringe tightly, Lou forced the needle against the top of the third rib, and then drove it to the hilt, over the bone and into Meacham’s chest. The jet of air, under great force, actually blew the plunger out of the syringe. Lou twisted the syringe from the hub of the needle, set it on the tray, slid the catheter into Meacham’s chest, then quickly sutured it to the skin. Air continued to hiss out as the collapsed lung struggled to reexpand.

Blood pressure, eighty over fifty. Color slightly improved. O
2
sat, seventy-two.

“Chest tube kit, please,” Lou said firmly.

“Here you go, Doctor,” Turnbull said, replacing the used steel tray with a fresh one and opening the setup used to insert a much larger tube.