Flashback

CHAPTER THIRTEEN

Dose by dose, microgram by microgram, the Haldol level in Annie Doucette's blood had been rising, The input from her senses, barely adequate to keep her oriented before the tranquilizer was started, had become blunted and distorted. Her periods of lucidity, even in the bright, noisy daylight hours, had all but disappeared. Now, as the muted stillness of late Sunday evening drifted over the hospital, what little hold she had been able to maintain on reality had begun to slip away.

One moment, she was home, in her own room, her own bed, in the next, she was someplace else, someplace at once foreign and familiar. It was evening, it was morning. Desperately, she struggled against the madness.

Desperately, she tried to focus her thoughts. Still, nothing was certain-nothing except the realization that somehow, she had wet and soiled herself. Call Zack… Call Suzanne, her mind urged. Tell them to come and clean you up. Tell them to get you out of this place. She turned to search for a telephone, but a wave of dizziness and nausea forced her back onto the pillow. Lifting the sheet, she stared down at her legs. Foul-smelling, loose excrement was smeared over the insides of her thighs. So disgusting. So humiliating. Must get washed… Must get showered before someone comes. Annie peered through a gray mist toward the door of her bathroom. Shower… Clean up… Then call-who? What was his e?

With all her strength she struggled onto her side. There were metal railings along both sides of her bed. Using one of them, and battling the constant spinning, she pulled herself up. How disgusting… How humiliating… There was no guard railing at the end of the bed. With agonizing slowness she worked her way over the feces-soaked sheet. Then she dropped one leg over the low foot board and onto the chilly linoleum floor. The dizziness was becoming unbearable. Still, she knew she had to get clean. An inch at a time, she slid her other leg onto the floor.

With every ounce of her strength, she tried to stand. Momentarily, her leg held. But then suddenly, it gave way, and for the briefest time she was floating in air. She landed heavily and gracelessly, air exploding from her lungs with a loud grunt. There was another sound as well-a sharp, snapping sound coming from somewhere within her body. An instant later, unimaginable pain shot through her from her left hip. Second by second, the pain intensified. Then, a heaviness settled onto her chest.

Slowly, the dim light in the room faded, and Annie felt a merciful, peaceful darkness settle in. The night was heavy-overcast and humid, with not quite enough breeze for comfort. It was nearing eleven when Zack eased the Judge's Chrysler into the largely empty parking lot outside the Ultramed-Davis emergency ward. The Judge, hands folded stoically in his lap, sat next to him. His mother, grim and silent, rode in the backseat, working over the handleerchief she had balled in her fists. Annie Doucette was in trouble. Zack would have much preferred to evaluate the woman's situation before involving his parents, but a well-meaning nurse, unable to reach Annie's son in Connecticut, had noted that they were listed in her record as "employer, " and had called them. A fractured hip and new coronary were the only snatches a shaken Cinnie Iverson could remember to repeat to Zack from that conversation.

"Zachary, dear, " she said now, as he helped her from the car, "do you think they'll operate on her tonight?"

"I don't know, Mom. It's doubtful, though. Especially if the nurse I spoke to is right about her having had a new heart attack."

"Her doctor-what is his name?"

"Norman, Mom. Don Norman."

"Dr. Norman. Did you speak to him?"

"He was in working on Annie. I didn't see any sense in bothering him."

"And did Frank say he'd be right in?"

"Yes, Mom. He's waiting for Lisette to get back from her sister's, and then he'll be in."

Cinnie gave her handleerchief one last squeeze and then stuffed it in her purse. "Well, " she said, "I just hope Annie's okay."

"Okay?"

Clayton Iverson laughed disdainfully. "Jesus, Cynthia, what world do you live in? The woman's almost eighty years old and she just fell out of bed, broke her hip, and had a heart attack. How in the hell could you possibly think she'd be okay?"

"Sorry, " Cinnie said. "There's no need to cuss, " she added in a whisper directed more to herself than to her husband. They entered the hospital through the emergency ward and took the elevator to the second floor. Annie had been moved back to the intensive care unit. I "Why don't you two wait in there, " Zack said, motioning them into the small waiting room just outside the unit. "I'll be back as soon as I find out what's going on."

Anger and tension had knotted the muscles at the base of his neck and were gnawing at the pit of his stomach. To be sure, over the years of his training he had had patients fall out of bed, even when strict precautions had been taken. The risk was always there, especially with so many hospitalized patients being old and infirm.

But this situation was different. Since he was a consultant on her case, Annie Doucette was, technically, his patient, but even more than that, she was his friend. In some ways she had been as much a parent to him as had Cinnie and the Judge. And even beyond that, he knew, was the special, proprietary feeling experienced by every physician toward a patient whose life he or she had saved. He was on edge, his physician's detachment and objectivity hanging by the thinnest of threads. From the moment Cinnie had called him with the news, he had been reminding himself that, while it was reasonable for him to be upset, there was seldom, if ever, justification for a physician to lose objectivity-even when confronting oversight or negligence. In the microcosm of the hospital, explosions by physicians helped no one. As he was heading into the unit, Sam Christian, one of three staff orthopedic surgeons, emerged. He was a tall, gaunt man, in his mid-fifties, who walked with a slight limp. Twenty-two years before, Zack and his mangled left knee had been one of his first cases. "Evening, Zack, " he said, He glanced into the small waiting room. "Judge, Cinnie."

"Hello, Sam." The Judge came out to shake his hand. "What's the story?"

Christian shrugged. "She needs a new hip, " he said matter-of-factty.

"But until her cardiac situation gets straightened out, that's out of the question. Tomorrow, if she's still-I mean, if she's settled down, I'll put some pins across the joint to stabilize it until we can do something definitive."

"Do you know what happened? " Zack asked. "Were the side rails up on her bed?"

Christian's expression darkened. "You'd best talk to Don Norman about all that. But yes, apparently the railings were up. She went off the end."

"Oh, dear God, " Cinnie gasped. "Thanks, Sam," Zack said. He turned to his parents. "I'll be out in a little bit."

As he entered the unit he heard the Judge say, "So, Sam, level with me, now. Who screwed up here?"

Zack had seen Annie briefly during morning rounds. At that time, she was awake and responsive, but somewhat depressed and more lethargic than she had been. He suggested that she try spending more time out of bed, and had actually offered to walk down the hall with her. She refused, citing a headache and lack of sleep. The change in her over just fourteen hours, even allowing for her accident, was terrifying. She was disoriented and combative, her speech was thick and slurred. Her gray hair was matted against her scalp with perspiration and bits of feces.

From the doorway, Zack watched as Don Norman struggled to examine Annie's chest. The portly internist had stripped off his suitcoat and rolled up his shirt-sleeves, but he was still wearing his tie, vest, and gold watch fob. Beads of sweat dotted his fleshy forehead and upper lip.

A young nurse stood off to one side, her face drawn and pale. "Need an extra pair of hands? " Zack asked as Norman stepped back from the bed.

The man looked down at Annie and then shook his head. "No, thank you, Doctor, " he said. "I'm just about done."

"She okay?"

"If you mean is she going to die, the answer is no… at least not tonight. Since we got a line in and gave her some fluid, her pressure has come up. But she's extended her old coronary. There's not much question about that. And I guess you know that she's fractured her hip."

She's extended her coronary. She's fractured her hip. Norman's emotionless statement-his tacit implication that Annie was responsible for her own misfortune-instantly rekindled the dislike Zack had developed toward the man during their interview many months before.

Still, there could be no arguing the truth in his grim assessment of her situation and prognosis. Pneumonia, stroke, embolism, heart failure, while orthopedists could work near-miracles with hips in the operating room, physicians and nurses knew all too well that immobilization of any sort was the deadliest enemy of advancing age. Zack moved to within two feet of the bed. "Is she making any sense?"

"Nope. Strictly word salad."

"Stroke? "

"I don't think so."

"Is there any evidence she hit her head?"

Norman shifted uncomfortably. cci. I haven't really checked," he said.

"As you can see, she's not the easiest thing in the world to examine right now."

"Mind if I try?"

"Try anything you want, " Norman responded somewhat testily. Then he glanced over at the nurse. Zack caught the look and warned himself against doing anything that would embarrass the man. He took Annie's hand. Instantly, she dug her nails into his palm. "Hey, Annie D, leggo!

It's me. It's Zack. I need that hand for my coin tricks."

She looked up at him, blinking as if struggling to peer through a haze.

Then, slowly, she loosened her grip. "Do you recognize me?" Zack said, already speeding through a neurologic exam. Annie did not respond.

"Well, you should." He checked her scalp for any telltale lumps, and her neck for any points of tenderness. "You used to wipe my runny nose and drag me back to the bathroom to wash behind my ears. Remember that?"

Although it remained uncertain whether or not Annie recognized him, there could be no doubt that his words had calmed her down. She lay reasonably still as he checked her eardrums and retinae. "Well?" Norman asked. His arms were folded tightly across his chest. Zack smoothed Annie's matted hair off her forehead. "There are — no focal neurologic signs. Let's go out to the nurses' station and talk, ekay?"

"Is it… all right if I listen in? " the nurse asked, pausing between words to clear a huskiness from her voice. "Fine with me, if Dr. Norman doesn't mind."

Norman hesitated and then shook his head. "We haven't met, " Zack went on. "My name's Iverson, Zack Iverson. I'm the new neurosurgeon on the block."

"I'm Doreen Lavalley, " she said. "Annie was my patient up on four. I feel sick about what happened. We had her tucked in with the side rails up. She soiled herself. I think she was trying to get to the bathroom when she fell. We were all in with a post-op patient who had started hemorrhaging, and our routine bed check was delayed almost an hour, and … and we're just She bit at her lower lip and d away. "Go on, " Zack said as they walked from the cubicle to the nurses' station. For a moment, it seemed as if the young woman was going to cry. Then a flash of anger mixed with the anguish in her eyes. "Dammit, " she said, "I knew something like this was going to happen."

"What do you mean?"

She glanced over at Donald Norman and then turned again to Zack. "We're short, " she blurted. "That's what I mean. We're short a nurse on every shift on every tloor except the unit here. It's been that way for more than a year. First they got rid of the union with all those promises of increased pay and benefits and staffing, Then, just slowly enough so that none of us could organize to complain, they began to cut back on nursing. I knew something like this was going to happen. I just knew it … Her fists were clenched in frustration. "Who's they'? " Zack asked.

"The hospital, that's who… the administration… Mr. Iver-" She stopped in midword and looked sheepishly at Zack. "Oh, great… Way to go, Doreen… Brother?" Zack nodded. "Sorry, " she said. "Don't be.

Don, you're the chief of staff. Are the physicians aware that this has been going on?"

Norman's face was pinched and flushed. However, his indignation was directed not at the situation, but at the nurse. "If Miss Lavalley has complaints about this hospital or the way it is run, " he said, his back almost turned to her, "there are channels established for her to voice those concerns. She's worked here for enough years to know that-and also to know that airing her own distorted point of view in the middle of the intensive care unit is not one of those channels. Now, Doctor, if you'd care to share your thoughts on Mrs. Doucette with me, I can get on with the business of trying to save her life."

The woman tensed at Norman's rebuke, but said nothing. Zack wrestled against the urge to defend her, and won a narrow victory.

The issue at hand was getting Annie Doucette diagnosed, treated, and stabilized. The nurse's charges, disturbing though they were, could wait. He thought about calling Suzanne in, but quickly tabled the notion. Annie's monitor pattern was regular, at least for the moment, and Donald Norman, as thin-skinned as he was thick-wasted, seemed hardly the sort to welcome any encroachment on his authority. "So?

" Norman asked impatiently, "Well, there's no evidence for a stroke or for head trauma, " Zack said, "but she's clearly disoriented, I guess if I had to put a label on what's going on, I would say she's sundowning-especially if her blood chemistries all come back normal."

Out of the corner of his eye, Zack saw Doreen Lavalley nodding in vigorous agreement. Sundowning was not a medical diagnosis in the pure sense. Nevertheless, to anyone dealing with elderly, hospitalized patients, the disorientation and psychotic behavior stemming from unfamiliar surroundings and the diminished sensory input of evening were as real and reproducible a phenomenon as a strep throat. "Excellent,"

Norman said, his expression and patronizing tone making it clear that Zack had added nothing to his assessment of the case. "Good job. Listen, Doctor, why don't you dictate a note, and I'll put a formal request for a consultation in her chart." He unrolled his sleeves and retrieved his suitcoat. "If there's nothing else, I'm going to see another patient.

I'll stop back on my way out."

Zack, engrossed in Annie's chart, did not respond. "What are you looking for? " Norman asked. "An explanation."

"For what? " Zack glanced up. "Don, this woman's been here almost two weeks, during which time she's been totally with it. Don't you think it's a little strange that she should have taken this long to sundown?"

"On second thought, " Norman said, "why don't you just forget about the consult. We'll discuss this whole thing in the morning."

"It's there, Dr. Iverson, " the nurse said. Norman shot her a withering glare. "What is? " Zack asked. "The explanation. Look on the med sheet."

"Give me that chart," Norman snapped. "Miss Lavalley, you don't know a good thing when you have it, do you? You just get the hell out of here.

I'll deal with you tomorrow."

"You can deal with me tonight, Dr. Norman, because I've had enough. I quit."

"Haldol! " Zack exclaimed, slamming his fist on the page. "What in the hell is she doing on Haldol?"

The nurse's fury was not uncontained. "Dr. Norman-excuse me, Don-" she corrected herself sweetly, put her on it Tuesday when she complained about his plan to transfer her to a nursing home. He called her a harpy."

"Damn you, " Norman hissed, his face now puffed and crimson. "A nursing home? Norman, are you crazy? " Is who crazy? " Frank Iverson, hands on hips, stood just inside the unit door. Zack rubbed at the grit of fatigue and tension that had begun to g his eyes. "This whole place, that's who, " he said to no one and to everyone. "This whole place is crazy."

"Easy, Zack-o, " Frank warned. "Just stay cool. How's Annie? " Zack lowered his hand and looked up at his brother. "She's crazy. That's how she is. She's crazy because for the last five days she's been receiving a major tranquilizer. Her blood levels have been rising and she's been drifting further and further from reality until it's doubtful she even knew where she was when all this happened. She lost control of her bowels and was trying to crawl over the end of the bed to the bathroom when she fell. The nurse, here, tells me they didn't get in to check on her as soon as they should have because there's been such a staffing cutback that they're shorthanded. What kind of a goddamn place is this, Frank?"

"I… I think I'd better get back to my floor," Doreen Lavalley said softly. "Mr. Iverson, my resignation will be in the nursing office tomorrow morning." Without waiting for a response, she whirled and hurried out. "Don, what in the hell's going on here? " Frank asked.

"Your brother, that's what," Norman answered. "He barges in here, starts examining my patient without even being consulted, badgers the nurse into making some rash statements about the hospital, and then accuses me of causing the woman to fall." He turned to Zack. "You've been trouble since the day you got here, and don't think we don't all know it. This hospital needs team players, Iverson. You're a grandstander.

Ultramed-Davis ran perfectly smoothly before you showed up, and it will do just as well after you've gone."

"I'm not going anywhere, " Zack said. "Don't bank on it, " Norman shot back. "Easy, both of you, " Frank said. "First of all, just tell me, is that woman in there going to die tonight?"

"It was touch and go for a while," Norman said. "But I've gotten things under control. She's a bit disoriented, but she's not in any immediate danger. We'll wait a few days to let her cardiac situation calm down, and then Sam Christian'll fix hey hip."

"Zack?"

"What?"

"Do you think that's the way it is?"

"I think, " Zack said wearily, still resting his head on his hand, "that Suzanne ought to be called in to take care of Annie. That's what I think."

"Over my dead body, you arrogant son of a bitch, " Norman rasped.

"Careful, Don, " Zack said. "That's Frank's mother you're talking about."

"Will you two please stop it?

There are nurses and patients all over this place. Now, Don, tell me, did you have Annie on a tranquilizer or not? And for God's sake, keep your voice down."

Donald Norman was losing what little control he had left. "First of all, Frank, " he said, "I'll thank you not to tell me what to do with my voice. Second of all, I'll thank you and your brother, here, not to go questioning the therapy I choose for my patients. You may be the administrator here, but i'm the chief of the medical staff."

Frank stepped forward until his face was less than a foot from Norman's.

His eyes were steely. "Donald, one call from me, one"-he held up a finger for emphasis — "and you'll be lucky to have a job scrubbing bedpans. You should know that. And if you don't think I have that kind of clout at Ultramed, just try me. Now take that chief of staff crap and stuff it. Then tell me what in the hell you were thinking when you put Annie Doucette on tranks."

"Yeah, Don, " Zack urged acidly, "tell him."

"Zack, will you please shut the fuck up for a minute and let me get to the bottom of this?"

Norman was visibly cowed. "Frank, " he pleaded, "I was just trying to follow policy. The woman's DRG payments are about to run out. I have a bed lined up for her at the nursing home. That's just what I'm supposed to do. When I told her what was planned, she went berserk. She demanded more time in the hospital. That was out of the question. You know the rules as well as I do."

"What rules?

" Zack asked. Frank ignored him. "So you sedated her, " he said. "Jesus, Don. She worked for my goddamn family. Couldn't you have just called me?" 91… I didn't think to,"

"What rules? " Zack asked again. "Yes, what rules? " The three men spun toward the voice. Clayton Iverson was just a few feet away, calmly appraising them all. His expression was nonthreatening, but Zack could see anger smoldering in his eyes. "Judge, " Frank said. "You said you were going to wait out there with Mom."

"I got impatient,"

"Well… well, good enough. I'm sure it's no great news to you that we can't always agree on everything in a hospital. Right?"

"Right."

Frank smiled cheerily, but Zack knew he was shaken. "Don, here, tells us Annie's still disoriented, but that her condition has stabilized. Isn't that so, Zack? Listen, Judge, why don't you get Mom and bring her in.

It's getting late, and I'm sure you both want to get on home."

The Judge confronted him in a brief eyeball-to-eyeball showdown, but Frank easily held his own. "All right, Frank, " Clayton said evenly. "As long as things are under control."

"Don's an excellent internist, Judge, and Annie's getting his best shot.

Right, Zack?"

"Right." Zack nearly choked on the word. "Don, come, " Frank said.

"Let's you and I go over some things before you call it a day."

Without waiting for an answer, Frank took Norman by the arm and led him from the unit. "How much of all that did you hear, Judge?"

Zack whispered. Clayton Iverson looked over at Annie, who was clumsily picking at the restraint that was holding her to the bed. "Enough, Zachary, " he said. "I heard quite enough. I'm going to have that letter in Leigh Baron's hands tomorrow. Are you going to try and talk me out of it?"

Once again, Zack rubbed at the burning in his eyes. Even faced with this new reality, it was painful to accept that the promise of Ultramed-Davis-the sparkling physical plant and progressive approach to medicine-was no more than a veneer. Beneath the sheen, beneath the new equipment, the new specialists, and the intense public relations effort, the hospital had no soul. "No, Judge, " he said finally. "Tomorrow I'm going to give you a look at the material Guy had put together against Ultramed. You go ahead and do whatever you feel you have to do. I'm not going to try and talk you out of anything."

Zack waited until the Judge had left, and then called Suzanne. "Zachary, do you know what time it is? " she said blearily. "Gee, no, " he said,

"but give me a minute, and I'll see if I can find someone who does."

"That's not funny."

"Sorry. You don't sound so hot."

"I'm not. I have a splitting headache, and sixty milligrams of Dalmane had me barely asleep when you called."

"Sorry again."

"I've just got to get some rest. Was there anything special you wanted? "

"No, " he lied. "Nothing special. I just wanted to see how you were."

"Oh… well, can you call me in the morning?"

"Sure."

"Thanks. I should go before this Dalmane wears off." 4"Good-" The dial tone cut him off. The atmosphere in the shingled ranch Zack had leased from Pine Bough Realty was kept musty and comfortable by the lingering aroma of decades of hardwood fires. It was after one in the morning.

Seated in a frayed easy chair by the dormant hearth, Zack sipped from a cup of Constant Comment tea, absently scratched Cheap dog in his favorite behind-the-ear spot, and waited. Frank had asked him to stay up to talk, and had promised to be right over. But Zack knew that his brother had never marched to anything other than Frank Iverson's time.

In truth, it made little difference how late Frank would be. Zack was too keyed up by the events of the evening to sleep. His feelings disappointment, anger, frustration-were strangely akin to those of the dreadful night when Connie had finally leveled with him about her decision to break off their engagement and not to accompany him to New Hampshire. "It wasn't supposed to be like this, Cheap, " be said. "It wasn't supposed to be like this at all."

So much of him wanted to just pack up and run-load the camper and go back to Muni. For all of its underfinanced, stretched-to-the — limit turmoil, the place at least had heart. The bottom line there was never anything but sick or hurting patients and a crew of nurses, technicians, and docs determined to help them get well. But even as he heard the crunch of his brother's Porsche on the gravel drive, Zack knew that he would stay. For Suzanne and the mountains, for Guy and Toby Nelms and all of the Stacy Millses yet to be in his life, he would see things through. Frank's visit did not last long. He was speaking even before the screen door had shut behind him. "You really stuck it to me tonight, Zack-o, " he said breathlessly. "You really stuck it to me."

"Have a seat, Frank. You want something to drink? Some tea? A beer?"

At that moment, Zack caught the odor of whiskey and noted the fine, red flush at the corner of Frank's eyes. "I don't want anything except a little goddamn loyalty and help from my brother, " Frank said, making no move to sit. "A good nurse has quit, my father, who also happens to be the chairman of the hospital board, is furious, and my chief of staff wants to shoot me, to say nothing of what he wants to do to you. That's great, Zachary. That's a hell of a night's work."

"Easy, Frank. Okay?"

"No, damnit! Not okay. Norman's right. From the minute you got back here there's been nothing but trouble. Playing Sir Lancelot all over the goddamn hospital, undermining my authority and Ultramed's policies, even flirting with my wife, for Chrissake."

"That's ridiculous. Frank, you've been drinking. Why don't we both just sit on this and we'll talk in the morning."

"I'll talk about it now, " Frank snapped. Having, perhaps, seen and heard enough, Cheap dog growled a soft warning and from somewhere beneath the shag of his face, bared his teeth. Zack glanced over at the animal, but made no attempt to quiet him down. With Frank less than totally rational already, Cheap dog was some insurance against a major blowup. That the dog was basically a coward would remain his secret.

"All right, " he said wearily, "so talk."

Frank was pacing, elenching and unclenching his fists and then rubbing his hands on the sides of his trousers. "For years now, ever since you fell on that ski slope and I got to go to Colorado, you've been waiting for the chance to get back, to ruin me. Sitting in the stands all those years cheering and clapping with the others, and all the while hating my guts because you couldn't stay on your skis-"

"Frank, that's crazy."

Revising upward his estimate of how much Frank had had to drink, Zack could only settle back in his chair and watch. "I told them things were going just fine up here, " Frank ranted on. "I told them we didn't need any goddamn neurosurgeon, least of all you. Well, let me tell you something, Zack-o. Tougher nuts than you have tried to fuck with me.

Where are they now?"

He whirled and leveled a finger at Zack's face. From the corner of his eye, Zack saw Cheap dog again stiffen. "Now just listen, and listen to me good, " Frank said. "Things are going to change around here or you're out. I've worked too hard to get this place the way I want it to have anyone screw it all up-especially someone with a twenty-year-old chip on his shoulder. So just back off. Let up on the staff, on the Judge, and on Lisette, or I swear, Zack-o, I'll come down on you like a ton of bricks."

Without waiting for a response, he spun on his heel and stormed from the house. Moments later, the Porsche screeched away. Zack sat in numb disbelief. A twenty-year-past skiing accident, an innocent, unfulfilled high school romance. Was Frank merely drunk and tired, or was he truly crazy?

Let up on the staff. The warning would have gone unheeded under any circumstances. But now, there was not even room for dialogue or tact, An eight-year-old boy was drifting toward insanity and possibly death, and, consciously or not, someone at Ultramed-Davis knew why. Zack glanced at his watch. It was after two. He picked up a book of crossword puzzles that were far enough beyond his ability to be soporific, and shuffled to the bedroom. What he needed now, more than anything else, was some sleep, because warning or no warning, Frank or no Frank, he was going to get some answers-beginning in less than seven hours with Jack Pearl.