Flashback

CHAPTER TEN

Although operating room 2 at Ultramed-Davis was newer than some of the dozens Zack had worked in, the ambience was no different. The sounds, the lighting, the tile, the filtered air-tinged with the unique mix of antiseptic and talc and freshly laundered gowns-provided sensations as familiar to him, as reassuring, as the mountains. The stabilization of Stacy Mills's neck was proceeding flawlessly. Standing by the head of the table, Zack paused, savoring the sensations — the wonder of what he was able to do, and the bond he was feeling with the rest of the O. R. team. The sound system-Frank's brainchild, now installed in nearly all Ultramed's hospitals-was playing George Winston's magical treatment of "The Holly and the Ivy."

"All set? " he asked the scrub nurse. The woman nodded. "All right, then, " he said evenly. "Stacy, this is the part I told you about. We're going to twist those four screws into place on your head. I've put lots of novocaine in each spot, so they won't hurt, but it will feel funny, and you might hear the grinding noise. Everything is going Just fine. I know it's scary for you, but there's really nothing to be frightened about."

"I'm not frightened, " the girl said. "At least, not too much."

"Good. And you remember what you have to do?"

"Don't move, " she answered. "Exactly…"

Zack checked the position of the cervical halo one last time, and worked the four screws farther into place through the small incisions he had made in the girl's scalp. "Unless I tell you to, don't move."

From a spot several feet behind the O. R. team, Wilton Marshfield watched, his every breath a sigh of relief. Even though Zack Iverson had publicly gone out of his way to share credit for the pickup with him and had privately assured him that this sort of cervical fracture was the toughest of all to diagnose, he sensed that he would never be truly comfortable in the emergency ward again. He had come out of retirement and into the E. R. as a favor to Frank Iverson, and because he was bored. Now, he knew, it was time to stop. And thanks to Iverson's brother, after forty years of busting his hump, of doing his best to survive first the knowledge explosion, then medicare and the paperwork crunch, then the malpractice crisis, and now the goddamn corporate-policy crap, he could at least go out as something of a winner. "God love ya, kid, " he said softly, as Zack tightened the apparatus in place. "God love ya."

"Okay, Stacy, " Zack was saying, "that's one. Now, wiggle your toes the way I showed you. Good. Now your fingers. Good, good. We're almost there."

He stepped back for a moment and shifted his focus from the metal frame to the fine features and peaceful face of the girl/woman. Biology, organic chemistry, anatomy and physiology, boards and more boards, endless nights and weekends on duty or on call, countless meals of cafeteria food or nondescript leftovers in cardboard containers, countiess hours in the O. R. and on the wards, scattered days, and weeks, and even months of consuming self-doubt-at moments like this one, the choices he had made in his life and the price he had paid made so much sense. And when it was over, when the girl who loved to ride horses walked away from the hospital and from the split second that could have paralyzed her forever, he would take that moment and bankroll it in his mind as vindication for all the years and all the anguish, and as a hedge against those outcomes yet-to-be which would not bring smiles and handshakes and pats on the back-outcomes that, as long as they were unavoidable, were no less a part of medicine than this one. "That's it, Stacy, " he cooed as he tightened down the last of the screws. "That's it. You're doing perfect. We're all doing perfect."

With the elective surgery schedule now an hour behind, O. R. 2 was emptied out as soon as the last screw was in place and the proper position of the halo was verified. Zack accompanied Stacy Mills to the east-wing room where, for a few days, she would be observed for signs of spinal cord swelling or compression. "Well, you just take it easy, Stacy, " he said. "I'm going to go talk to your folks, and then I'll send them up. I'll be back to see you at the end of the day. Wearing this device won't be the most fun you've ever had, but like I said, it won't be forever."

"Dr. Zack, " the girl called out as he was leaving, "in the operating room I said that I wasn't scared. Well, now that it's all over, I can tell you that I really was. I just didn't want to sound like a baby."

Zack returned to the bedside and smiled down at her. "In that case, " he said, "I've got something to tell you-something I've never told any patient before." He bent over her bed and whispered, "I'm always a little frightened and a little nervous when I operate."

"You are? Really?"

"The truth. I think it helps my concentration never to forget that it's always possible that something could go wrong. There, I said it, and..

hey, Dr. Mills, I feel better already!"

"You're very silly, do you know that?"

"I hope so, " he said. As he was leaving the girl's room, Zack spotted Maureen Banas approaching down the corridor. She was in her late forties or early fifties, he guessed, with short, graying hair that looked as if it had been cut by an amateur. Although she carried herself with authority, the tension etched into her face and the lack of attention to ten or fifteen excess pounds hinted at a life that had, perhaps, not been an easy one. "Congratulations, Dr. Iverson, and thanks, " she said with an almost clinical lack of emotion. "Stacy is a very special child to a lot of people. We all owe you a great deal for what you did."

In that case, he wanted to say, tell me about the nail you helped hammer into Guy Beaulieu's coffin. "Listen, " he replied instead, "just-seeing her moving those arms and legs and piggies of hers is enough to get me through six months of the usual neurosurgical nightmares. Besides, it's Wilton Marshfield you should be thanking. I was just the technician."

"Nonsense. I know he missed those fractures. Sticking up for him was a very kind thing for you to do, especially with the altercation you two had last week. Wilton's really a sweet old guy most of the time. But he misses too much."

He misses too much. The opening, however slight, was there. Zack glanced past the nurse. The corridor was quiet. There might have been a more appropriate time and place, but one day after Guy's funeral, and only hours after reading his diary, thoughts of the man were too close to the surface for Zack to walk away from this opportunity. "Sort of like Guy Beaulieu in that respect, " he said. "Yes?"

Maureen Banas looked at him queerly. "I beg your pardon?"

"I was asking about your impressions of Guy Beaulieu. I was with him when he died, you know."

"Of course I know." Her strange expression had not faded. "I thought a lot of Dr. Beaulieu. To die the way he did was… was very tragic."

She averted her gaze and peered around the corner into Stacy's room.

"Well, " she said, "I guess I'd better check on my niece and get back to the emergency ward. Thank you again, Doctor."

"Mrs. Banas, wait, please, " Zack said. The woman stopped, her back still to him, her posture rigid. "Please? " he said again. Slowly, she turned to face him. Her arms were folded grimly across her chest. "Yes?"

"Mrs. Banas, I… I read the letter you wrote about Guy."

What little color there was drained from the nurse's face. "Your brother had no right to go passing that around," she said. The woman looked about restlessly. "Dr. Iverson, I think I'd better go."

"Mrs. Banas, just a minute ago you said that you owed me a great deal for what I did for Stacy. Well, I don't usually call in markers like this, but I need to know about Guy-what he's been like these past two years, what he did that prompted you to write those charges. Please.

It's terribly important to me… and to his family."

Maureen Banas's reaction was far from the anger or defensiveness Zack would have anticipated. She began to tremble, and quickly grew close to tears. "I… please, I don't want to talk about it. Your brother said he would speak with me before showing that note to anyone. He had no right to give it to you."

"Look, " Zack said. "I didn't mean to upset you. I'm just trying to get to the bottom of things-to the truth."

It took several breaths before the nurse began to regain her composure.

"Dr. Iverson, I've got three children, one of them retarded, and an ex-husband who hasn't sent a dime of support in ten years. I'm sorry I wrote that letter, but… but I had to. I had to. Now, you've got to leave it alone. For my sake. For my family. Leave it alone. I beg you."

"I can't, Mrs. Banas… Maureen, I don't want to cause trouble for you or for anyone, but I've got to know if that letter contained the truth about Guy… Please." The woman said nothing. "What is it? " he asked.

"Did someone pressure you to write it? Threaten to take your job away?"

The nurse bit her lower lip. Her eyes had filled with tears. She glanced nervously about. Two nurses were approaching down the hall. "Come with me, " she said softly. There was a small sitting area at the end of the corridor-a colonial-style maple settee and two matching chairs arranged beneath a huge picture window that faced southwest, toward the mountains. Maureen Banas took one of the chairs and motioned Zack to the edge of the settee closest to her. "Dr. Iverson, I meant what I said about my family, " she began in a hoarse whisper. "If you speak of this conversation to anyone and I lose MY job, you will have hurt a number of people who do not deserve to be hurt."

"You have my word."

"I… I'm terrified about doing this."

"Please…"

"At the beginning of the summer, I qu'tteled with Dr. Beaulieu in the E.

R. We never got along all that well to begin with, but I think we more or less respected one another. It doesn't make any difference what we fought about. The whole incident was actually pretty mitd. But there were a number of witnesses. "A week or so later, there was an envelope stuck under my door at home. In it were ten one-hundred-dollar bills, a copy of the note you saw, and instructions that when I copied the note over in my own hand and sent it to Mr. Iverson, I would receive a second, equal payment."

"No hint of who the note was from?"

Once again, the nurse seemed close to breaking down. "None. "Well, did the note say what would happen if you refused?"

"It said that trouble would start happening in my life, and that I could count on being fired. Dr. Iverson, I know what I did was awful, but… but I had been doing so poorly with the kids, and the damn bills just keep coming in, and-"

"Please, Maureen. You don't have to explain, " Zack said. "I understand that you did what you had to do. Do you still have the note?"

The nurse shook her head. "I. I was afraid to keep it."

"Any sense at all as to who sent it? Do you think it was my brother?"

Zack felt sick at the thought. "I… I don't believe so," she said.

"Why do you say that?"

"Well, whoever wrote me added at the end that if Frank Iverson learned my note wasn't really my idea, he would be tired just as quickly as I would be…"

She began to cry. "You see why you can't say anything to anyone about this?"

"Yes, Maureen. I see. Telling me what you did was a very brave thing to do. I promise you that I'll honor your confidence,"

"Th-Thank you."

She dabbed at her eyes with her uniform sleeve and then hurried back down the corridor. Feeling more sadness toward the woman than anger, Zack propped his foot on one of the chairs and gazed across at the Presidential Range. Hikine,… climbing… camping… unique challenges in the office and in the O. R… The projected life that had drawn him back to Sterling suddenly seemed so remote, so naive. Guy, it appeared, had been right all along. Someone at Ultramed was committed to driving him from practice-and in the ugliest of ways. Zack was grateful that that someone did not appear to be Frank. But in the end, would it really matter? In Sterling, at least, Frank was Ultramed. And when push came to shove, it was hard to imagine him lining up against the company.

The situation was so crazy, so far removed from a patient needing help and a physician trained and ready to render it. But for better or worse, Zack acknowledged, he was in It to stay.

He had chosen this town and this hospital. And now, if he had to do battle with Ultramed to justify that decision, then battle there would be. All he needed to complete the circle, to place himself once and for all squarely where Guy Beaulieu had stood, was proof-if not proof from Maureen Banas, then perhaps from the Ultramed system itself. If Guy was right, if the policies and the climate created by the corporation were so ruthless and self-serving, if compromises were being made and corners cut in the name of profit, then somewhere there was the medical tragedy such a philosophy must inevitably bring. Somewhere, there was that emotional focal point that would translate possibilities and abstract concerns into flesh and blood.

And if such a tragedy existed, Zack vowed, sooner or later he would find it. From his position at the nurses' station on West 2, Donald Norman, MD, propped Annie Doucette's chart on his ample lap and peered over the top of it at a Rubenesque young nurse named Doreen Lavalley. She was standing on tiptoes atop a small stool, stretching over her head for a bag of IV solution. The skirt of her uniform was at her mid-thigh and rising. Doreen was the sexiest, most desirable woman in the hospital, at least to the Ultramed-Davis Chief of Staff. For months he had been cultivating her with small talk, friendly pats on the shoulder, an arm about the waist, and impromptu teaching sessions. Since his arrival at the hospital four years before, Norman had gone out of his way to keep his reputation spotless and to portray the perfect, responsible family man and community servant. The powers at Ultramed rewarded such behavior just as vigorously as they punished actions that brought negative publicity down upon their house. But after four consecutive yearly merit awards, he believed that the company would tolerate a few slips. And with his wife gaining weight and growing more involved with her school committees and steadily less involved with their physical relationship, Doreen Lavalley had become worth the risk. Besides, Norman reasoned, Frank Iverson was rumored to have made it with half the decent-looking women in the hospital, and he had been made a member of the Golden Circle and had twice won the highest administrator's award that Ultramed offered. Just as her skirt was about to reach the base of her panties, Doreen located the right IV solution and hopped down from the stool.

Donald Norman cursed under his breath. "Morning, Doreen, " he said, tugging at the small bulge that had materialized behind Annie Doucette's chart. "How goes it?"

"Oh, Dr. Norman, hi."

"Hey, I told you, " he whispered, with a conspiratorial wink, "when no one's around you can call me Don. Listen, I'd like you to make rounds with me, if that's okay. Mr. Rolfe has some interesting findings in his chest, and that… that harpy, Mrs. Doucette, should still have her murmur."

The nurse glanced about. "Well, I'm a little behind in my work, and-"

"Oh, come on, " he urged. "I just have these two on this floor. It shouldn't take long."

"I… well, okay. As long as it's just two. And Dr. Norman, Annie's a nice lady. Really she is. Just give her a chance."

"It's Don, remember? " Norman said. "And as far as Annie Doucette goes, she may be a sweet old lady to you, but she's been a harpy to me." He checked the three by five file card he carried on her. "Besides, " he added, "It's all academic. To all intents and purposes, she'g out of here."

"You're sending her home? " Doreen asked with disbelief. Norman shook his head* "Not home, " he said. "To the Sterling Nursing Home, provided they can clear out a bed. Remember, under the Diagnostically Related Group system-you know, the DRGS-medicare pays by the diagnosis, not the length of the hospital stay. Our job is to get patients out as quickly as possible."

What Norman did not mention, although they were certainly on his mind at that moment, were the Ultramed incentive points awarded for discharging patients before the end of their DRG period, and the even greater number offered for a transfer to a Leeward-owned nursing facility. "I don't think Annie's going to like that idea, " the nurse said. "She's very independent."

"Well, then, " Norman said, tucking her chart under his arm and adjusting his tie, "we'll just have to reason with her, won't we? Bring your order book along just in case. By the way, " he added as they started off, "I'm giving an in-service on hepatitis next Thursday evening. I hope you'll be there."

"Well, actually, I-"

"I think Flo Bergman, the Ultramed nursing director, will be up from Boston. I'd like her to meet you. With the Ultramed director of nursing and the Davis chief of staff on your side, there's no telling what opportunities might open up for you…"

Annie Doucette flipped off the quiz show she had been trying to watch, settled back on her pillow and stared up at the ceiling. The pains in her chest, little more than twinges throughout the previous day, had begun to intensify, and for the first time since the horrible night of her admission, she was frightened. There were gaping holes in her recollection of that night, but not gaping enough to erase the agony and the humiliation she felt, to say nothing of the disruption she had caused Cinnie Iverson, the Judge, and their family. She should never have accepted their invitation to dinner, she told herself. Never. After twenty-odd years of doing her work proudly and well, of being the glue that held the Iverson household together, she had become nothing but a burden-an imposition and source of worry for everyone. If only she could have just gone as her husband had, quickly and painlessly in his sleep.

She chewed two Rolaids from the pack her son had bought for her and tried to focus her thoughts on the sweaters for her grandchildren and the afghan for the church bazaar-unfinished projects waiting for her at home in her flat. All she needed was a few more days-a week, maybe-in the hospital, and everything would be okay. She had not given in to the aches and pains and the passing years yet, and she would not this time.

The rumblings in her chest were probably nothing more than indigestion, anyhow. Annie closed her eyes as bit by bit the discomfort yielded to a gentle sleep… A week… That was all she needed… A week to get her strength back… Then everything would be okay… everything would be back to nonnal again… It felt so good to nap… So good to drift off… so good… "So, Mrs. Doucette, how are we doing this morning?

" Donald Norman boomed. Startled, Annie felt another, slightly more urgent twinge in her chest. "We have felt better, Dr. Norman, " Annie said, opening her eyes only after the last vapor of sleep had drifted away. "Oh, hello, Doreen, dear."

"Hi, Annie."

"And what seems to be the trouble? " Norman asked. Annie debated whether or not to repeat what she had already told the nurses about the pains.

Donald Norman had never paid much attention to her complaints, anyway.

"I'm getting some pains," she said finally. Norman thumbed through her chart. "Doreen, look. Here's the description I wrote of that murmur.

Right here. A grade-two systolic. Let's listen and see if it's changed."

He slipped his stethoscope down Annie's nightgown, listened for a few moments, and then guided the nurse to the bedside with his arm around her waist and gave her a turn. "Hear it?"

The young woman looked at Annie uncomfortably and nodded. "Dr. Norman," she said, "Annie's been having chest pain on and off since yesterday morning."

"Of course she has, " Norman said, as if he and the nurse were the only two in the room. "I would bet dollars to doughnuts that they started right after I mentioned her discharge from the hospital. It happens all the time. People get anxious. Did you order an EKGT' "It's right there in the front of her chart."

"Good, " he said. "Good work." He scanned the tracing. "Well, it shows nothing to be alarmed at. Just the same T-wave changes in the anterior leads. Here. See? Right here. I'll explain how they're different from other T-wave changes after we finish seeing these two patients." He turned back to Annie. "So, if everything else is okay, I think we should begin to plan for your discharge."

"I'm not feeling well enough to leave yet, Dr. Norman."

"I know, dear. I know."

Norman took her hand to pat it, but Annie pulled away. "You're bound to be nervous at the prospect. That's why I've arranged for you to-"

"I wish to stay in the hospital for another week or so, " she said.

"Then I should be ready to go home."

"Mrs. Doucette, you didn't let me finish. I was saying that I'm in the process of arranging a bed for you at the Sterling Nur-uh, convalescent facility. A couple of weeks there, and you should be ready to go home."

"I won't go, " Annie said flatly, sitting up in bed to confront the man.

"You are not going to stick me in any nursing home. I shall stay here for one more week, and then I shall go to my own home."

"I'm afraid that's not possible, Mrs. Doucette."

"Well, " she said, "I'll just speak with Mr. Frank Iverson, and we'll see what is possible and what is not."

"Feel free to do that if you wish, Mrs. Doucette. But Frank Iverson is not taking care of you. I am. And I am telling you that your hospitalization is about to run out and you will not be able to remain here for another week. That is the rule. In fact, it is one of the rules Frank Iverson is paid to uphold. Now, please calm down and try to realize that what I'm doing is in your best interests." Before she could respond, Annie felt another stab beneath her breastbone. Under the sheet, her fists clenched. "You're not a very good doctor, you know," she managed finally. "You not only don't take very good care of yourself, you don't take very good care of your patients, either."

Donald Norman glanced back at Doreen Lavalley, his face flushed with anger and embarrassment. The old woman was a goddamn harpy, there were no two ways about it. Not only was she jeopardizing a hefty set of bonus points for him, but she was making him look like a goddamn asshole in front of Doreen, as well. "Mrs. Doucette, " he said sternly, "we'll discuss this later. Meanwhile, lie back and get some rest. Doreen, come with me, please."

He turned on his heel and stalked from the room. The nurse looked down at Annie and shrugged helplessly. "I'll be back a little later, " she said. "I want her to get some Valium, " Norman ordered when they were out of earshot. "No, no, on second thought, make it Haldol, one point five by mouth every eight hours. Give her the first dose now."

Doreen Lavalley hesitated. Norman smiled at her and patted her on the shoulder. "Hey, Doreen, don't worry, " he said. "This is absolutely routine stuff. Nobody wants to go to a nursing home, but some people have to. And listen, I didn't get to be chief of staff in this system by not caring about my patients. If anything, I care too much. "Believe me, it's all for the best. The Haldol will calm her down, and by this evening she'll be a thousand times easier to reason with. You just watch. Okay?… Now, about my in-service talk next Thursday. What do you say we… "