Code Blues (9 page)

Robin shook off her grip and clanked the
glass on the coffee table. "There's no need to swear."

We all burst out laughing.

Robin looked slightly annoyed, but he didn't
pull out the o.j. again.

Mireille said, "I heard you guys. Don't
worry about bringing Alex to St. Joe's. He can sleep it off
here."

Robin made a face. She
turned on him. "Look. Kurt
died
today. Alex is going to be fine in a few hours.
If you're so worried, Robin, you can stay with him tonight. But we
should be talking about Kurt, not Alex. That's the least we owe
him, on the day he died." Her voice broke on the last word, but her
green eyes were steely and dry as she stared at each of us in the
eye.

Tucker said, "Okay." His voice was calm.
"Let's talk about Kurt. Who wants to start?"

Mireille pointed a finger at me. "I want to
know what happened."

"No one knows what happened yet. But I'll
tell you what I saw." I described finding him in the men's change
room, the aborted code, the screaming girlfriend, the police
officer. My throat tightened. This wasn't just a guy who had spoken
to me at orientation. He was a man, a mentor, a teacher, a doctor.
What a loss. But I described the scene as best I could. Some people
need to see the body, to believe that the person is dead. My
description was the best substitute for tonight.

Mireille pressed her hand to her forehead,
but she leaned forward, intent on every word. When I fell silent,
she said flatly, "He knew how to use his insulin. He did not
overdose on it."

Tucker tried to touch her shoulder, but she
twitched away. "I know this, Tucker." She glared at me. Her hands
clenched into fists. "No. It was something else. It's bad enough
that he's dead. I don't want anyone to blacken his name."

Tori said, "No one is accusing him of
anything. We all loved him, Mireille."

"Did you?" Mireille said. "What did you love
about him, Tori? I would very much like to hear it."

Tori met her gaze levelly. "I respected him.
He was a good teacher. He cared. He had a sense of humor."

Tucker took a step forward. "Remember how
he'd swing his briefcase down on the conference table and say,
'What have you got for me today, kids?'"

Anu and Tori laughed, Mireille loosened her
arctic look. Tucker grinned, encouraged. "He made me laugh every
single time I reviewed a case with him. No one else could do that.
Lots of docs want to show off and make you feel stupid."

I silently remembered Dr. Callendar from
this morning.

"Kurt was never like that. If I didn't know,
he'd say, 'Look it up and tell me about it next time.' He respected
us, even though we were just medical students. He encouraged us to
go into family medicine. He really was a mentor."

"Evidence-based," murmured Robin.

We all ignored him.

Thinking of Alex, I said, "I heard that Kurt
was good at listening to people."

Anu nodded. "I remember, on my first day at
the FMC, he said, if you have any problems, talk to me. I'm always
here for you."

"So did Bob Clarkson," Tucker noted.

Everyone except me laughed. Bob Clarkson.
The putative head of the FMC. I raised an eyebrow at Tucker. "Did
anyone talk to Bob?"

Mireille rolled her eyes.

Tucker blew his breath out through his nose.
"No one in his right mind would talk to Bob about anything
important."

"Why? Is he a dink?"

They laughed again. Tucker said, "You met
him, right? At orientation? Nice guy, but not a whole lot upstairs.
Very hung up on protocol."

Mireille said, "Once I asked him about
improving Internet access at the FMC. He said to call his secretary
and make an appointment to talk about it. Then I did, but he spent
the whole meeting talking about himself and how good the FMC was
already, without the Net!"

"Kurt was kind of the heart of the FMC,"
said Tori quietly. "We'll all miss him."

Anu sniffed back a tear. She turned toward
the stereo, to hide it, but Tori handed her a napkin. She wiped her
eyes. The room got very quiet.

"There's something else." I hesitated. I
didn't want to make a huge deal out of it, but I thought everyone
should know. "I, uh, went through Dr. Radshaw's pockets—the police
told me I shouldn't have, but I didn't know—and he wasn't wearing
his pager."

Silence. Broken by Mireille's hissed breath.
"I knew it!" She threw her head back, eyes squeezed shut. "I knew
it, I knew it."

Tori took a step toward her, but when
Mireille opened her eyes, they were exultant. "Someone killed
him."

My thought exactly, but I hadn't appeared so
happy about it.

"Thank you," she said to me.

I glanced around. Everyone looked confused,
except Robin, who looked blank. He was probably sorting through his
mental file of articles, figuring out which ones applied for
evidence-based treatment of bizarre behaviour.

Mireille smiled. "We all know he'd never go
anywhere without his pager. It was like his lover. The killer took
it away after murdering him." She grabbed my arm, her fingers
sinking painfully into my flesh. "What about his cell phone? He
always carried it too, so he could call back right away."

I tried to ease my arm out of her grip. "I
didn't see any cell phone. Just his glucometer and his wallet."

"Yes!" Spit flew out of her mouth and landed
on my cheek. I jerked back. She laughed, said sorry, and handed me
a napkin from the pile on the coffee table.

At least she'd stopped gripping my arm.

As I wiped my face, I had to add, "But if he
was hypoglycemic, he might've—"

Tucker was nodding
thoughtfully, but Mireille's hand shot out as if to snap my words
out of the air. "
Non
! I am telling you, I knew him better than anyone in this
room, and he never left home without his pager clipped to his belt
and his cell phone in his left pocket!"

The ring of agony in her words silenced
us.

Tori laid her hand on Mireille's forearm. I
could see Mireille's muscles clench in her arm and in her jaw, but
she forced herself to take a deep breath. "Okay. Good. I wanted to
talk about Kurt. We did. So thank you. Please, let's eat some more.
There's plenty of food."

I felt obliged to take a few more sips of
water, and Tucker complimented Tori on her garlic bread, but we all
started shuffling our feet and taking peeks at our watches.

"Thanks for inviting us," Tori said.

With a relieved sigh, we rose to our feet.
Robin shoved Alex into recovery position and propped him up with
cushions from the sofa, but Robin was the first to take off without
bothering to air-kiss Mireille's cheeks. The last thing I saw, when
I waved goodbye, was Mireille's green eyes staring at me from the
doorway. She no longer pretended to smile.

Chapter 7

It was almost a relief to go to work the
next day. I wasn't sure what to think anymore. I'd arranged Henry
into so many positions, I'd finally left him sitting with his
knobby hands together, roughly approximating prayer position. No
more bad luck, please.

In fact, I started off with a stroke of
fortune. Dr. Dave Dupuis was on again for my evening shift, while
Dr. Callendar was nowhere in sight. Dr. Dupuis looked calm and
stork-like again, as he sat in a wheeled black chair at the nursing
station, his feet propped on the base. "Hi there," he said. "You
all right?"

Close enough. "Yeah. You?"

He nodded. "I've got a good chest pain in B.
Go look at her."

Right down to business. I liked that.

In resus room B, I introduced myself to Mme.
Cartier, an 82-year-old woman. Behind the white flannel blanket she
clutched to her chest, her blue gown sagged so low on her chest
that I could see her protruding ribs. Her hands were like the
stereotypical witch's claws, the fingers bent and knuckles
thickened by arthritis, the nails horn-like and filed to a
point.

She was a bit hard to understand, because
she'd forgotten her dentures at home and tended to mumble, but I
understood that she'd had a burning chest pain for the last two
days, radiating to her neck and jaw. She hadn't come in until this
afternoon. "I thought it was nothing."

Her daughter, a brunette
with careful makeup, picked up the story. "She thought it was her
stomach.
Toujours mal au coeur, eh,
maman
?" She turned back to me. "She
doesn't want to come to the hospital all the time."

"So what was different this time?"

The daughter screwed up
her face in thought. "More—intense, eh,
maman
? She called me, but by the
time I convinced her to come—" She shrugged as if to say, What can
I do?

I wasn't getting much of a story out of the
two of them, so I picked up the EKG. My eyes popped. Big ST
elevation from V1 to V4.

"What do you see?" Dr. Dupuis came up behind
me.

I pointed it out, and whispered, mindful of
the patient, "Big anterior." A big heart attack. A bad one.

"Uh huh. And did you listen to her chest?
And see her chest X-ray?"

I had jumped right from history to the EKG,
so I backtracked to the physical exam. I listened to her heart and
chest and checked her abdomen. The most remarkable finding was poor
air entry and crackles at both lung bases.

I walked out of resus to the hallway between
the ambulatory and acute (stretcher) sides, where the light boxes
were posted. Mrs. Cartier's X-ray was already up. Instead of nice,
black, air-filled lungs, they were quite white from fluid both in
and around the small air sacs called alveoli. Congestive heart
failure. When the heart doesn't beat hard enough, as in Mrs.
Cartier's case, because she had had a heart attack, the fluid backs
up into the lungs.

I found Dr. Dupuis in the nursing station,
sitting by the monitors. I said, "We have to thrombolyze her."

He tipped his head back to look at me. "Do
we? What are the criteria?"

"Well, she has a big ST elevation in four
contiguous leads, and she's had chest pain for more than six
hours—"

He smiled. "Yes, but she's been having pain
for how long?"

I pressed my lips together. Damn. "Two
days."

"And how old is she?"

I sighed. "Eighty-two." After more than
twelve hours of chest pain, and over age seventy-five, the benefits
of thrombolysis—lysing the clot, reducing death and recurrent heart
attacks—drops significantly. By now, the risks outweighed the
benefit. I could cause this lady's brain to bleed, instead of
solving her heart attack.

Dr. Dupuis watched me work it out. Then he
said, "You could make an argument for thrombolyzing her, because
it's a big anterior. But I'd rather do rescue angioplasty. She's
supposed to go over to the Jewish, whenever they can take her.
She's hemodynamically stable, but we have to watch her. Read up on
thrombolysis and PCI."

"Okay." Pretty cool case. Then I went to see
a 90-year-old man. According to his son, the patient had fainted
and hit his head on the sink. I was spotting a trend in St. Joe's
emerg patients: old and frail. Well, except for Dr. Kurt yesterday,
and he'd been beyond our help.

I shook my head steered my mind back to the
case at hand. I smiled at the patient. He'd put the hospital gown
on over his ribbed white undershirt and tighty-whities. "Had you
just urinated or had a bowel movement, sir?"

He looked puzzled, twisting to check with
his son. "No."

I wasn't a pervert. Voiding and defecation
stimulate the vagal nerve, which could make a patient faint. But
otherwise, I was running out of questions to ask. I needed to read
up on syncope, too. I fumbled around some more, and when I couldn't
think of anything else, I did a physical exam. The guy had a goose
egg on his forehead. His right eye was starting to swell shut. No
lacerations to sew, though. The rest of his exam was pretty
normal.

When I reviewed this case with Dr. Dupuis, a
nurse interrupted. "Dave, can 11 go?"

They debated discharging
bed number 11 while
I wanted to call him
Dave, too. Like I said, at Western, it wasn't uncommon for
residents to called staff physicians by their first names. I wanted
that promotion. He probably wouldn't mind. Still, I decided to
defer that until I got to know him better. After he finished with
the nurse, I said, "So, it's a 90-year-old man with
syncope."

Dr. Dupuis replied, "So what do you
think?"

Did he not hear my history and physical? I
stared at him blankly. "Well, it's syncope."

"But what do you think caused it? How do you
want to investigate it?"

He expected me to manage this patient as if
I were a real doctor. Man. Here was my real promotion. As a med
student, getting the H&P was my main job and managing the case
was a bonus, but not expected, unless I was running the floors at
night on surgery or medicine. As a resident, I had to pull my
weight during the days, too. I started going through the algorithm
I'd been taught. Was this neurogenic, meaning brain-based, like a
seizure? Cardiac, meaning heart-based, like a heart attack or
arrhythmia? Or the combination of neurocardiogenic, like blood
pooling in the legs? Dr. Dupuis listened patiently, even as nurses
interrupted him: "Dave, bed 14 won't stay in the room. I want
sedation." "Dave, number five is still in pain." "Dave, does two
still need the monitor? I've got a chest pain in triage."

Somehow, he was able to sort through these
and still keep a mind on my story. He asked, "Do you think this guy
had a seizure?"

"No. I mean, I could ask again, but he
didn't have any seizure-like activity, and he didn't bite his
tongue and he wasn't incontinent. He said he was oriented when he
came to."